REHABILITATION IN PARAPLEGIA



centercenterA PROJECTEntitled“REHABILITATION IN PARAPLEGIA”Submitted ToThe Department Of PhysiotherapyI.T.S PARAMEDICAL COLLEGE24949150 Affiliated ToCHAUDHARY CHARAN SINGH UNIVERSITY, MERRUTIn The Partial Fulfillment of Degree OfBACHELOR OF PHYSIOTHERAPYGuide Submitted By Dr Shubhra Narang Vishakha puri March 2010CERTIFICATEThis is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” by VISHAKHA PURI BPT 2006-2010 Batch , Enroll No._____________has been completed in the partial fulfillment for the degree of Bachelor of Physiotherapy from C.C.S. University, Meerut, U.P., India. I recommend him/her for the award of BPT Degree. DR.C.S.RAMDIRECTORDEPT. OF PHYSIOTHERAPYI.T.S PARAMEDICAL COLLEGECERTIFICATEThis is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” is conducted by VISHAKHA PURI in the partial fulfillment for the degree of Bachelor of Physiotherapy under my guidance and supervision . GUIDEDr SHUBHRA NARANGMPT NEUROLOGY(i)CERTIFICATE OF ORIGINALITYI hereby declare that the project work entitled “REHABILITATION IN PARAPLEGIA ” embodies the original work by me . This work in part or full has not been submitted to any other university for award of degree. I shall not publish the contents of this project in part or full without the written consent of my guide and college.VISHAKHA PURIB.P.T 2006-2010 BatchEnroll. No. ________(ii)ACKNOWLEDGEMENTI would like to express my sincerest gratitude to the following individuals without whom this study would have been unattainable.I offer my sincerest gratitude to Dr. Shubhra Narang (M.P.T) whose guidance constructive concel , unmatchable suggestions and unstinted encouragement enlightened me throughout the project.I express my heartiest gratitude to Dr. C.S. Ram , H.O.D , Department Of Physiotherapy , I.T.S Paramedical college for kindly permitting us to pursue research work.I am thankful to Dr. M Thangaraj , Dr. Stuti Sehgal , Dr. Tanu Shrivastava , Dr. Kanika Govil , Dr. Ekta for their constant inspiration and support in pursuing the study .I would like to thank my colleagues Ashish gautam , Pooja sinha , Priyenka tyagi and Yukti sharma for their co-operation in my project .Remarkable co-operation and dedication by the subjects laid milestone for the success of project completion.And finally thanks to all those who have contributed directly and indirectly towards this study.VISHAKHA PURI(iii)DEDICATEDTOMY PARENTSANDALL MY FACULTY(iv)TABLE OF CONTENTSCertificate ( Guide) iCertificate Of Originality iiAcknowledgement iiiDedication ivList of figures v-viList of Tables vii1) INTRODUCTION Anatomy – The basis of injury classification Epidemiology Mechanism of injury Designation of lesion level2) TYPES OF LESIONS IN SPINAL CORD Complete injury Incomplete injury a) Central cord syndrome b) Anterior cord syndrome c) Brown sequard syndrome d) Posterior cord syndrome e) Cauda equine syndrome f ) Sacral sparing Stages after spinal cord injury a) Stage of spinal shock b) Stage of reflex activity c) Stage of reflex failure 3) CLINICAL MANIFESTATIONSDirect Impairments a) Autonomic dysreflexia b) Impaired temperature regulation c) Orthostatic hypotension d) Bladder dysfunction e) Bowel dysfunction Indirect impairments a) Pressure sores b) Deep venous thrombosis c) Contractures d) Heterotopic ossification e) Pain4) HOSPITAL MANAGEMENTPrehospital management Immediate management of patient with spinal cord injury a) transfer from the site of emergency b) assessment of ABCDE c) neurological status examination d) skin inspection e) temperature examination f) bladder function Investigations Fracture stabilization Pharmacological management REHABILITATIVE MANAGEMENT Acute phase rehabiltation Active phase rehabilitation Transition phase of rehabilitation ( 6 ) BIBLIOGRAPHY (7 ) APPENDICESAppendix AAppendix BAppendix CAppendix DLIST OF FIGURESFigure 1): Etiology of spinal cord injury Figure 2) : Types of thoracolumbar fracturesFigure 3) : Central cord syndromeFigure 4): Anterior cord syndromeFigure 5): Brown sequard syndromeFigure 6) : Cauda equine syndromeFigure 7): Stage of spinal shockFigure 8) : Autonomic dysreflexiaFigure 9): Pressure soreFigure10) : Deep venous thrombosisFigure11): Heterotopic ossification (a) Hip (b) KneeFigure12) : Harrington rod Figure13) : Jewett braceFigure14) : Phenol peripheral nerve blockFigure15) :Negative pressure vacuum techniqueFigure 16) :Elastic support stockingsFigure 17):Tilt tableFigure 18):RollingFigure 19):Supine to long sitting positionFigure 20):Prone on elbow position Figure21) :Prone on hand positionFigure22):Quadruped position Figure23): Kneeling position(v)Figure24): Push up weight shiftFigure25): Bed to wheelchair transferFigure26): Wheelchair to bed transferFigure27): Wheelchair to car transferFigure28): Car to wheelchair transferFigure29): Wheelchair to toilet transferFigure30): Toilet to wheelchair transferFigure 31) : Wheelchair to bath seat transferFigure 32) : Bathseat to wheelchair transferFigure 33 ) : Oswestry standing frameFigure34): Orthosis prescribed in case of paraplegicsa) Knee ankle foot orthosisb) Scott craig orthosisFigure35): Standing from wheelchair with crutchesForward techniqueSideway techniqueBackward techniqueFigure 36): Crutch balancingFigure 37): Ambulation activities with crutches Swing to gait Swing through gaitFour point gaitFigure38): Partial body weight support treadmillFigure39): Functional electrical stimulation(vi)LIST OF TABLESTable 1 : EtiologyTable 2 : Mechanism of injuryTable 3 : Pharmacological management of spasticityTable 4 : Pharmacological management of painTable 5 : Correlation of complete injury levels and orthosis prescriptionABBREVIATIONS USEDLMN - Lower motor neuron UMN - Upper motor neuron SCI - Spinal cord injury DVT - Deep vein thrombosis PaO2 - Partial pressure of oxygen BP - Blood pressure CT Scan-Computed tomographic scan MRI - Magnetic resonance imaging IM - Intramuscularly IV - Intravenously TENS- Transcutaneous electrical nerve stimulation KAFO- Knee ankle foot orthosis RGO - Reciprocal gait orthosis AFO - Ankle foot orthosis FES - Functional electrical stimulation Ft - Feet # - Fracture N - Normal I - Intact PT - Performance timeRep - Repetitions Sec - Seconds H - Hold Res - Resistance(vii)434340247650 CHAPTER 1INTRODUCTION ( SIMILARLY FOR OTHER CHAPTERS) Spinal cord injury is a central neurological disorder1 . It occurs due to damage to neurological components in spinal cord occurring as a result of primary or secondary effects of disease or trauma 2. Spinal cord injury is a low incidence , high cost disability requiring tremendous changes in an individuals life style3 . Normal events of life driving a car, diving into lake or walking down stairs can suddenly results in life changing injury with physical and lifestyle constraints that totally refigure the realities of daily life .SPINAL CORD INJURY ANATOMY – THE BASIS OF INJURY CLASSIFICATION The term spinal column refers to the vertebral column bones and disc that collectively encases and protects the soft tissue of the spinal cord .The spinal cord is made up of nerve tracts carrying signal back and forth between the brain and rest of the body4 .Figure 1: Incidence of spinal cord injury(2)ETIOLOGY10 TraumaRoad traffic accident , Gun shot wounds.Non traumatic factorsTumours Meningioma , astrocytoma , metastatic tumour in spinal cord Ischaemia Arteriosclerosis , dissecting aortic aneurysms Developmental disorders Spina bifida , meningomyelocele Neurodegenerative disease Friedreich's ataxia , spinocerebellar ataxia, Transverse myelities Resulting from stroke or inflammation. Vascular Malformation Arteriovenous malformation , dural arteriovenous fistula , spinal hemangioma , cavernous angioma and aneurysm. Demyelinating disease Multiple sclerosisTable 1 : Etiology of spinal cord injury(3)(5)Figure 2 : Thoracolumbar fracturesEND OF CHAPTERSBIBLIOGRAPHYBooks ReferredSusan B O’ Sullivan , Thomas J Schmitz : Physical Rehabilitation and Assessment and Treatment (Fifthedition) : chapter 23 : Traumatic spinal cord injury : page 932-9Cameron Monroe : Physical rehabilitation : chapter 20 : Non progressive spinal cord disorders : page 539-573Ida Bromley : Tetraplegia and Paraplegia (fourth edition) : chapter 10-12 : Mat work , wheelchair and wheelchair management , transfers : page 95 – 115.Tidy`s Physiotherapy, Twelfth edition , Ann Thompson , Alison Skinner , JoanPrierly : chapter 7 : 229-243Darcy. A. Umphred : Neurological Rehabilitation : Fourth Edition :Chapter 16 : Page 477-530.Louis Solemom , Davi J. Warwick Silva Durai Nayagam : Apley`s System of orthopaedics and fractures : The spine : page 1130-1135Lorriane William Pedretti : Occupation Therapy Practice skills for physical Dysfunction 4th edition : Chapter 6 : 224-245 Kloth, Le and Feeder : Rehabilitaton in Occupational Physical Therapy : Page 334-356Ebnezer : Essentials of Orthopaedics and applied Physiotherapy: Chapter 23 : page 143-147Carolyn Kisner , LynnAllencolby : Theraputic exercises Foundation and techniques : section 2 : page 140 -174McKinnis, LN: Fundamentals of orthopedic radiology : Chapter 12 : Spinal cord Fractures : Page (1231-1268).Daniel`s L ,Worthingham C , Muscle Testing : Techniques of Manual Examination, 5th edition : Chapter 3 : Page 35-60Norkin`s CC, White DJ: Measurement of Joint Motion : A Guide to Goniometry : Chapter 4 : page 164-176 Morison, M.J. (Ed) . The Prevention and Treatment of Pressure Ulcers. St. Louis : Mosby, 2001 Chapter 31:The Prevention and Management of Pressure Ulcer : Page : page 636-647.Arthur C. Guyton, John E. Hall : Textbook of Medical Physiology: Chapter 54 : Motor Functions Of The Spinal Cord :The Cord Reflexes: Page 622-632.Kenneth W. Lindsay, Ian Bone : Neurology and Neurosurgery Illustrated : 3rd edition : Chapter 22 : Spinal cord and Root compression. Page : 377-390.Kissner Carolyn, Lynn Allen Colby : Theraputic Exercises Foundation and Techniques : Chapter 14, Chapter 15 :The Spine : Subacute , Chronic and Postural Problems : Page 531-576. Journals Referred:Houte SV, Vanlandewijck Y (2006) Respiratory muscle training in persons in persons with spinal cord injury : A systematic review: Respiratory medicine : 100 , (1886-1895).Waters RL , Adkins Rh (1991) Definition of Weurmser LA (2007) Spinal cord injury medicine : Epidemiology and classifications : Arch Phys Medical Rehabilitation : 88, (S49-S54).Nobunga AI, Go BK : Recent Demographics and injury trend sin people served by model spinal cord injury care system : Arch Physical Medicine Rehabilitation : 80,1372-1382.Andrew Swain, David Grundy : ABC of spinal cord injury : Chapter 1 : At the site of accident : Page (112-143).Waters RL, Adkins RH : Definition of complete spinal cord injury: Paraplegia 29 , 573-arr , AE : Autonomic Dysreflexia (Hyper reflexia) , Journal Spinal cord , 1997 : page 345-354Erickson, RP : Autonomic Hyperreflexia : Pathophysiology and medical management. Journal : Archives of physical medicime and rehabilitation, 1980 : 61:431Lamount LS: A Comparison of two arm exercises in patients with paraplegia: Journal : paraplegia : 1996, 61: Page 441-567Hussey RW and Stauffer ES : Spinal Cord injury: Requirements for ambulation: Journal : Archieves of Physical medicine and rehabilitation 1973 : 54:544.Mikel berg R, Reid S : Spinal cord lesion and lower extremity bracing: An overview and Follow up study : Paraplegia , 1999 : 379, 19.Bernardi M, Et al : The Efficiency of walking of paraplegic patients using reciprocal gait orthosis : Paraplegia : 2000 : 78 : 552-55912. Sipski ML, Delisa JA : Functional electrical stimulation spinal cord injury rehabilitation A review of literature. Journal : Physical therapy : 56 : 778-789.Web site referred : // http:// http:// 6) 7) http:// pubmed .com 8) http:// APPENDICES APPENDIX- (a)APPENDIX-(b)FORMAT FOR CASE REPORT-1 (please note it is of a different project)Name: Mrs. Kamlesh Age: 51 years Gender: Female Occupation: House wifeAny other recreational activity: NoAddress: Railway Road, New Defence Colony, Muradnagar, GhaziabadChief Complaint: Patient complaints of Low back pain since 3-4 months with the pain on the left side of buttocks.History of Past IllnessHistory of Previous similar Problem: Same type of illness occurs 2 year back, but the intensity of episode was less problematic then present.Any Previous traumatic History: History of fall from the stairs 2 years back. History of Present Illness:Yes A) Episode of illness: The illness started 8-9 years back. The episode is of recurrent low back pain with aggravation of symptom since 3-4 months. This is second episode of illness. B)Onset : (i) Pathological- Noa) Sudden - Nb) Gradual -Y (ii) Traumatic- Mechanism of injury- C) Site of pain: Pain is in lower lumbar region and the left side of buttocksY D) Is there is any radiation of pain: Yes/No- If yes: where it goes- It radiated form the lower back to the left side of buttocks till mid of thigh.No E) Is any paraesthesia / numbness / tingling sensation: F) Most preferred position of the patient: Lying in the supine position. G) Sleeping position of the patient: Patient preferred to lie in the right side lying position. H) Mattress used: Hard Surface I) Any other history: NoMedical HistoryDiabetesY/N√ Hypertension Y/N√Cardiac disease Y/N√Cancer Y/N√Tuberculosis Y/N√Infection Y/N√ Repetitive Coughing Y/N√Any other medical problem Y/N√Drug HistoryPast drugs History: NoPresent drug History: On Phase Medications - AnalgesicAllergic to any Drug: NoSurgical HistoryAny surgery: Hysterectomy has been done 5 years back. Date of Surgery: Not knownAny complication after Surgery: No.Bed stay after Surgery: 15 -20 days.Occupational History: - Home maker.Personal History: Smoking: NoAlcohol: NoDietary Habits: RegularHistory of Constipation: NoOther Details:Fever: NMalaise: NAny other joint problem: NAny bladder/ bowel symptoms like incontinence or retention NAny respiratory problemNSymptoms suggestive of major neurological disturbances NFrequency of episodes of pain: 1 attack before 8 years2 attack before 2 years3 attack before 3 monthsIntensity (VAS) (On first visit) - 9 out of max. of 10Type of Pain:Superficial- XDeep- √ Nature of Pain:Sharp- XDull- √Aggravating Factors: Pain is aggravated by prolonged sitting, standing, and bending forward.Relieving Factors: Patient got relief after lying in right side lying position.Does pain aggravates with coughing, sneezing: N (But previously it was present)XoOn Observation:Body type: Ectomorphic√MesomorphicXEndomorphicGait: Patient walks with the lordotic posture and takes precautionary measures during walking to avoid the jerk.Assistive device: NoXXX√Attitude of patient:Normal Tense Bored XX Lethargic Over anxiousSpinal posture: Standing: Patient was having protruded neck with excessive lumbar Lordosis.Lying: Patient lies in supine lying position and avoids bending forward while getting up from bed.Spinal curvature:XLumbar spine:Normal lordosisX√√√Excessive lordosisXFlat backXScoliosisSway back X√Thoracic spine:Normal KyphosisXExcessive kyphosisScoliosisAny Step off sign: No.Any presence of tuft of hairs: NoOthers: NoOn PalpationMuscle tone (Lumbar muscle): Tone IncreasedTenderness: PresentSite: Left PSIS and L3-L4 spinous process.Odema: AbsentSwelling: AbsentOn Examination:MOVEMENTS: JOINTMOVEMENTSACTIVEPASSIVE LUMBARFLEXIONP, TRP,TREXTENSIONNPNPSIDE FLEXIONLEFTRIGHTLEFTRIGHTNPPNPPROTATIONLEFTRIGHTLEFTRIGHTNPNPNPNPP- PAINFULNP- NON PAINFULIR-INITIAL RANGEMR- MID RANGETR- TERMINAL RANGERANGE OF MOTION:JOINTMOVEMENTSACTIVEPASSIVELUMBAR SPINEFlexion0-74*0-75*Extension0-18*0-20*Side FlexionRIGHTLEFTRIGHTLEFT62-4762-4962-4862-50*- signifies taken from the inclinometerEND FEELS:-Lumbar Flexion: Tissue StretchLumbar Extension: Tissue StretchLumbar Side Flexion:Right Tissue StretchLeftTissue StretchLumbar Rotation:Right Tissue StretchLeft Tissue StretchJOINTMOVEMENTSACTIVEPASSIVERightLeftRightLeftHIP JOINTFlexion0-1000-1000-1100-110Extension0-150-150-150-15Abduction0-350-350-400-40Adduction0-200-200-250-25Internal Rotation0-350-350-350-35External Rotation0-450-450-450-45END FEELS:-Hip Flexion: Right- Tissue Stretch Left- Tissue Stretch Hip Extension: Right- Tissue Stretch Left- Tissue Stretch Hip Abduction: Right- Tissue Stretch Left- Tissue Stretch Hip Adduction: Right- Tissue Stretch Left- Tissue Stretch MANUAL MUSCLE TESTING OF LUMBAR SPINEAbdominals : 4Lumbar Extensors : 4MANUAL MUSCLE TESTINGOF HIPHip Flexors: Left- 4+ Right- 4+2) Hip extensors: Left- 4+ Right- 4+3) Hip Adductors: Left- 4+ Right- 4+4) Hip abductors: Left- 4+ Right- 4+5) Hip Internal rotators: Left – 4+ Right- 4+ 6) Hip External Rotators: Left- 4+ Right- 4+MUSCLE LENGTH TEST:Hamstring test: NormalRectus femoris test/ Ely’s test: NormalMYOTOMES:Affected myotomes are: L3, L5DERMATOMAL EXAMINATION:Affected Dermatomes are: L3, L4, L5SPECIAL TEST:SLR: Negative for neural tissue Slump test- PositiveProne Knee Bending –NegativeBowstring test – PositiveValsalva maneuver- NegativeANY OTHER FINDINGS:PROVISIONAL DIAGNOSIS:Lumbar PIVD (L3, L4, L5) WITH RADICULOPATHYINVESTIGATIONS:MRI FINDING:MRI reveals: Disc Degeneration at L4-L5 levels Diffuse Posterior disc herniations with extrusion at L5-S1 Diffuse Posterior herniations with annular tear at L4-L5 level Disc bulge at L3-L4 DIAGNOSIS:LUMBAR PIVD (L3- L4-L5) without radiculopathy to left buttocks.PHYSIOTHERAPY TREATMENT:Treatment A: (10 DAYS)Hot pack for 15 minutesInterferential Therapy- 10 minutes, Four pole vector 45 degree scan, square waveform Traction: 20 Kg, intermittent traction with hold time 5seconds and relax time 20 second for the duration of 10 minutes is given in straight leg position.Treatment B: (Next 10 DAYS)Hot pack for 15 minutesTranscutaneous Electrical Nerve Stimulation- HI TENS, 2 channels, 1st at the nerve roots of L3, L4, and L5. 2nd channel at the nerve course at left buttocks for 15 minutesTreatment C: (Next 5 days)Ultrasound at the L4-L5 level- pulsed 1.2W/cm2 for 5minute and at the left sacroiliac joint pulsed 0.8 W/cm2 for 5 minutesTranscutaneous Electrical Nerve Stimulation- HI TENS, two channels, one at the nerve roots of L3, L4, and L5. two channel at the nerve course at left buttocks for 15 minutes HOME PROGRAM AND ERGONOMICS:1) Patient is advised to use the lumbosacral orthosis to support the back during travelling.2)Patient is advised for hot fomentation at home.3) Patient is advised to lying in prone lying position for at least 15 minutes duration twice in a day.4)Patient is explained about the proper sitting, standing, lying, and lying to standing, doing the household activities in a proper way.5) Patient is advised to take rest and to avoid the forward bending as much as the patient can avoid.Exercises:Protocol A: Pelvic tiltingHamstring StretchingSpinal RotationCalf StretchingNeck RaisingKnee RollingThese exercises are advised to be done twice daily for the 10 seconds hold time and 10 repetitions.Protocol B:Lying in extensionExtension exercisesBack and Gluteal exercisePROGRESS NOTE:Pain Reduction Progress: Visual Analog Scale (VAS):Dated: 0 5 10 No pain Mild Pain Severe Pain4/3/10- 5 out of max 109/3/10- 3 out of max 1017/3/10-1out of max 10The patient had the treatment A for 10 days continuous then the patient pain subsided to the lower lumbar back and slightly to the left buttocks area. All the lumbar muscle spasm has been also reduced.After 10 days the Treatment plan B started and continued for the 7 days. Now the pain was reduced to a limit and patient was able to do her ADL’s. Along with the treatment plan B, the patient was advised to start the exercise protocol A. But the patient had the slight tenderness at the lower lumbar spinous process.After that the treatment plan C was started for 5 days.Pictures Of assessment:Posture assessment: Tenderness checking: Fig 1 & 2 Fig 1Fig 2Two tender points: Fig 3Fig 3Lumbar movement assessment:Lumbar flexion and extension Fig 4 & 5Fig 4Fig 5 Measurement of lumbar range by inches tape (schobber’s test)Measuring Lumbar Flexion: Fig 6Fig 6fig 7 Measuring Lumbar Movement by Inclinometer:Fig 8Fig 9 Special test:PKBFig 10Slump TestFig 11 SLR TestFig 12APPENDIXASSESSMENT SCALESScale For Assessment Of Spinal Cord injury ASIA ScaleImpairment ScaleScale For Assessment Of Spasticity Spasm Frequency ScaleModified Ashworth ScaleScale for Assessment Of Pressure Sore Risk Bradens scaleScales For Assessment Of Activities of Daily LivingBarthel Index ScaleFunctional Independence Measure ScaleScale For Assessment Of AmbulationWalking Index Scale For Spinal Cord InjuryASIA Scale ( Standard neurological classification of spinal cord injury )Impairment ScaleA - Complete : No motor or sensory function is preserved in the sacral segment S4 -S5 levelB - Incomplete : Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4- S5C - Incomplete : Motor function is preserved below the neurological level and more than half of the key muscles below the neurological level have a muscle grade less than 3 .D- Incomplete : Motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a grade of 3 or moreE- Normal : Motor and sensory function is normalSCALES FOR ASSESSING SPASTICITYSpasticity Rating ScaleSpasm Frequency Scale0 - No spasms1 - One spasm or fewer per day2 - Between one and five spasms per day3 - Between five and nine spasms per day 4 - Ten or more spasms per dayModified Ashworth Scale0 - No increase in muscle tone1 - Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the part is moved in flexion /extension abduction or adduction1+ - Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM2 - More marked increase in muscle tone through most of the ROM, but the affected part is easily moved 3 - Considerable increase in muscle tone, passive movement is difficult SCALE FOR ASSESSING PRESSURE SORE RISKBraden Scale Patients Name _____________________________________ Evaluators NameName________________________________ Date of AssessmentSensory perceptionAbility to respond meaningfully to pressure-related discomfortCompletely LimitedUnresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished .level of consciousness or sedation / limited ability to feel pain over most of bodyVery LimitedResponds only to painful stimuli . Cannot communicate discomfort except by moaning or restlessness / has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body.Slightly LimitedResponds to verbal commands, but cannot always communicate discomfort or the need to be turned / has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.No ImpairmentResponds to verbal commands . Has no sensory deficit which would limit ability to feel or voice pain or discomfort .MoistureDegree to which skin is exposed to moistureConstantly MoistSkin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.Very MoistSkin is often, but not always moist .Linen must be changed at least once a shift.Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day.Rarely MoistSkin is usually dry, linen only requires changing at routine intervals.ActivityDegree of physical activityBed fastConfined to bed.Chair fastAbility to walk severely limited or non-existent . Cannot bear own weight and/or must be assisted into chair or wheelchair.Walks OccasionallyWalks occasionally during day, but for very short distances, with or without assistance . Spends majority of each shift in bed or chairWalks FrequentlyWalks outside room at least twice a day and inside room at least once every two hours during waking hours .MobilityAbility to change and control body positionCompletely Immobile Does not make even slight changes in body or extremity position without assistanceVery LimitedMakes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Slightly LimitedMakes frequent though slight changes in body or extremity position independently .No LimitationMakes major and frequent changes in position without assistance.NutritionUsual food intake patternVery PoorNever eats a complete meal . Rarely eats more than a of any food offered . Eats 2 servings or less of protein (meat or dairy products) per day . Takes fluids poorly . Does not take a liquid dietary supplement /or maintained on clear liquids or IV for more than 5 days.Probably InadequateRarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement / receives less than optimum amount of liquid diet or tube feedingAdequateEats over half of most meals . Eats a total of 4 servings of protein (meat, dairy products per day . Occasionally will refuse a meal, but will usually take a supplement when offered / is on a tube feeding or TPN regimen which probably meets most of nutritional needsExcellentEats most of every meal . Never refuses a meal . Usually eats a total of 4 or more servings of meat and dairy products . Occasionally eats between meals . Does not require supplementation.Friction and shearProblemRequires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . Spasticity , contractures or agitation leads to almost constant friction.Potential ProblemMoves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.No Apparent ProblemMoves in bed and in chair independently and has sufficient muscle strength to lift up completely during move . Maintains good position in bed or chair. SCALES FOR ASSESSING ACTIVITIES OF DAILY LIVINGFunctional Independence Measure ( FIM SCALE )The Functional Independence Measure (FIM) scale assesses physical and cognitive disability.Fim scaleSelf-care1. Eating2. Grooming3. Bathing/showering4. Dressing upper body5. Dressing lower body6. Toileting7. SwallowingSphincters1. Bladder management2. Bowel managementMobility1. Transfers : bed/chair/wheelchair2. Transfers : toilet3. Transfers : bathtub/shower4. Transfers : car5. Locomotion : walking/wheelchair6. Locomotion : stairs7. Community mobilityBarthel indexActivity ScoreFeeding0 - unable5 - needs help cutting, spreading butter, etc., or requires modified diet10 - independent ______Bathing0 - dependent5 - independent (or in shower) ______Grooming0 - needs to help with personal care5 - independent face/hair/teeth/shaving (implements provided)Dressing0 - dependent5 - needs help but can do about half unaided10 - independent (including buttons, zips, laces, etc.) ______Bowels0 - incontinent (or needs to be given enemas)5 - occasional accident10 - continentBladder0 - incontinent, or catheterized and unable to manage alone5 - occasional accident10 - continent ______Toilet use0 - dependent5 - needs some help, but can do something alone10 - independent (on and off, dressing, wiping) ______Transfers ( bed to chair and back )0 - unable, no sitting balance5 - major help (one or two people, physical), can sit10 - minor help (verbal or physical)15 - independent ______Mobility (on level surfaces)0 - immobile or < 50 yards5 - wheelchair independent, including corners, > 50 yards10 - walks with help of one person (verbal or physical) > 50 yards15 - independent (but may use any aid; for example, stick) > 50 yards ______Stairs0 - unable5 - needs help (verbal, physical, carrying aid)10 - independent ______TOTAL (0–100): ______SCALE FOR ASSESSING AMBULATIONWalking index scale for spinal cord injury (WISCI II)Physical limitation for walking secondary to impairment is defined at the person level and indicates the ability of a person to walk after spinal cord injury. The development of this assessment index required a rank ordering along a dimension of impairment, from the level of most severe impairment (0) to least severe impairment (20) based on the use of devices, braces and physical assistance of one or more persons. Level Description0 - Client is unable to stand and/or participate in assisted walking.1 - Ambulates in parallel bars, with braces and physical assistance of two persons, less than 10 meters.2 - Ambulates in parallel bars, with braces and physical assistance of two persons,. 10 meters.3 - Ambulates in parallel bars, with braces and physical assistance of one person, 10 meters.4 - Ambulates in parallel bars, no braces and physical assistance of one person 10 meters.5 - Ambulates in parallel bars, with braces and no physical assistance 10 meters.6 - Ambulates with walker, with braces and physical assistance of one person, 10 meters.7 - Ambulates with two crutches, with braces and physical assistance of one person 10 meters. 8 - Ambulates with walker, no braces and physical assistance of one person, 10 meters .9 - Ambulates with walker, with braces and no physical assistance, 10 meters.10 - Ambulates with one cane/crutch, with braces and physical assistance of one person , 10 meters11 - Ambulates with two crutches, no braces and physical assistance of one person , 10 meters12 - Ambulates with two crutches, with braces and no physical assistance 10 meters13 - Ambulates with walker, no braces and no physical assistance, 10 meters.14 - Ambulates with one cane/crutch, no braces and physical assistance of one person , 10 meters15 - Ambulates with one cane/crutch, with braces and no physical assistance 10 meters16 - Ambulates with two crutches, no braces and no physical assistance, 10 meters.17 - Ambulates with no devices, no braces and physical assistance of one person, 10 meters18 - Ambulates with no devices, with braces and no physical assistance, 10 meters.19 - Ambulates with one cane/crutch, no braces and no physical assistance 10 meters20 - Ambulates with no devices , no braces and no physical assistance, 10 meters. ................
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