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SCI C4 & C5Physical DysfunctionOCTA 2060Stephanie HuffJuly 18, 2014Table of ContentsDiagnostic Summary………………………………………………………………………………………………………………………………………………...........................................3-10Demographics of “typical” patient with SCI c4&c5…………………………………………………………………………………………………………………………………………11-13Treatment team and services…………………………………………………………………………………………………………………………………………………………………………14-17Identification of appropriate FOR and MOP’s…………………………………………………………………………………………………………………………………………………18-22Evaluation Methods ………………………………………………………………………………………………………………………………………………………………………………………23-30Impact on occupational performance…………………………………………………………………………………………………………………………………………………………….31-44Treatment plan………………………………………………………………………………………………………………………………………………………………………………………………45-48Discharge plan……………………………………………………………………………………………………………………………………………………………………………………………….49-50Presentation……………………………………………………………………………………………………………………………………………………………………………………….See AttachedSynopsis………………………………………………………………………………………………………………………………………………………………………………………………………………51References……………………………………………………………………………………………………………………………………………………………………………………………………..52-54DIAGNOSIS SUMMARYDESCRIPTION AND DEFINITION“Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in the cord's normal motor, sensory, or autonomic function, damage to any part of the spinal cord or nerves at the end of the spinal canal — often causes permanent changes in strength, sensation and other body functions below the site of the injury (Mayo Clinic).” C4 Spinal Cord InjuryMost severe of the spinal cord injury levelsParalysis in arms, hands, trunk and legsPatient may not be able to breathe on his or her own, cough, or control bowel or bladder movements.Ability to speak is sometimes impaired or reduced.When all four limbs are affected, this is called tetraplegia or quadriplegia.Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting in or out of bedMay be able to use powered wheelchairs with special controls to move around on their ownWill not be able to drive a car on their ownRequires 24-hour-a-day personal care(Shepherd Center) C5 Spinal Cord InjuryPerson can raise his or her arms and bend elbows.Likely to have some or total paralysis of wrists, hands, trunk and legsCan speak and use diaphragm, but breathing will be weakenedWill need assistance with most activities of daily living, but once in a power wheelchair, can move from one place to another independently(Shepherd Center)ETIOLOGY“Spinal cord injuries result from damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself. (Mayo Clinic).”Traumatic Spinal Cord Injuries?Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 40 percent of new spinal cord injuries each year. ?Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause more than one-quarter of spinal cord injuries. ?Acts of violence. As many as 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Institute of Neurological Disorders and Stroke. ?Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 8 percent of spinal cord injuries. ?Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries (Mayo Clinic).Nontraumatic Spinal Cord Injury?Diseases, cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries (Mayo Clinic).INCIDENCE AND PREVALENCEIncidence: It is estimated that the annual incidence of spinal cord injury (SCI), not including those who die at the scene of the accident, is approximately 40 cases per million population in the U. S. or approximately 12,000 new cases each year. Since there have not been any incidence studies of SCI in the U.S. since the 1990's it is not known if incidence has changed in recent years (NSCISC).Prevalence: The number of people in the United States who are alive in 2012 who have SCI has been estimated to be approximately 270,000 persons, with a range of 236,000 to 327,000 persons (NSCISC).SIGNS AND SYMPTOMSPain in the neck or backWeakness in the arms or legLoss of bowel or bladder controlLoss of sensation in the arms or legsInability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances (MedicineNet).Signs & Symptoms?Pounding headache (caused by the elevation in blood pressure)?Goose Pimples?Sweating above the level of injury?Nasal Congestion?Slow Pulse?Blotching of the Skin?Restlessness?Hypertension (blood pressure greater than 200/100)?Flushed (reddened) face?Red blotches on the skin above level of spinal injury?Sweating above level of spinal injury?Nausea?Slow pulse (< 60 beats per minute)?Cold, clammy skin below level of spinal injury (NCSIA)Treating a SCI as soon as the traumatic event occurs or whenever the sign and symptoms occur is a key component to receiving the best outcome. Not treating a SCI quickly can result in death, especially at the higher level injuries. The loss of sensation (paralysis) of a part or parts of the body is the most notable sign immediately following a traumatic event.COURSE AND PROGNOSIS“Recovery from a SCI requires long-term hospitalization and rehabilitation. An interdisciplinary team of doctors, nurses, therapists (physical, occupational, or speech), and other specialists work to medically manage the patient to control pain, to monitor the heart function, blood pressure, body temperature, nutritional status, bladder and bowel function, and attempt to control involuntary muscle shaking (spasticity). Rehabilitation focuses on preventing muscle wasting and contractures, and works to retrain the patient to use other muscles to aid in mobility and movement. Some of the important chronic complications of SCI include pressure ulcers ("bed sores") and pneumonia (Johns Hopkins Medicine).”“The prognosis for substantial recovery of neuromuscular function after SCI depends on whether the lesion is complete or incomplete. If there is no sensation or return of motor function below the level of lesion 24 to 48 hours after the injury in carefully assessed complete lesions, motor function is less likely to return. However, partial to full return of function to one spinal nerve root level below the fracture can be gained and may occur in the first 6 months after injury. In incomplete lesions, progressive return of motor function is possible, yet determining exactly how much and how quickly return will occur is difficult. The longer it takes for recovery to begin, often is less likely it is that it will occur (Early, 2013).” MEDICAL/SURGICAL MANAGEMENT “Medications may be used to manage some of the effects of spinal cord injury. These include medications to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel control and sexual functioning. Immobilization should be done immediately following the traumatic event that caused injury; you may need traction to stabilize your spine, to bring the spine into proper alignment or both. Sometimes, traction is accomplished by securing metal braces, attached to weights or a body harness, to your skull to keep your head from moving (halo). In some cases, a rigid neck collar may work. A special bed also may help immobilize your body. Often, surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity (Mayo Clinic).”PRECAUTIONS IMPACTING THERAPY“Autonomic dysreflexia (AD), also known as hyperreflexia, refers to an over-active Autonomic Nervous System, which causes an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. AD can develop suddenly and is potentially life threatening and is considered a medical emergency. If not treated promptly and correctly, it may lead to seizures, stroke, and even death (NSCIA).”A person with a c4-c5 SCI will usually have little to no sensation in their extremities. When the client is being moved, special attention to their extremities should be taken so that their arms and legs do not get Injured. Not using proper positioning/handling of a paralyzed client can result in a second disabling condition, such as DVT.Due to lack of sensation thermal regulation is another function that can be disturbed after SCI. Poikilothermic, which is a complication occurring the first year after the injury where the body assumes the temperature of the external environment. This can lead to discomfort and the bodies’ ability to conserve body heat, which puts the body at risk for hypothermia. Extreme temperatures should be avoided and attention should be given to the extent and type of clothing worn by the client at all times (Atchison). The risk of Postural Hypotension and DVT should also be noted during OT therapy. Both of these conditions result in cervical and thoracic SCI due to the reduced muscle tone in the legs and trunk. Decreased blood pressure results in postural hypotension can be prevented by the use of antiembolism hosieries and abdominal binders, which externally assist circulation. Symptoms include lightheadedness, dizziness, pallor, sudden weakness, and unresponsiveness. Client should be semi reclined or reclined potion should be maintained until symptoms subside. Deep Vein Thrombosis causes embolisms and can be life threatening if not detected. Clients at most risk for this 2 weeks post injury, however it remains a concern in higher SCI’s due to extent of paralysis. Signs of DVT are swelling in the LE’s, localized redness, and a low-grade fever.Avoiding Autonomic Dysreflexia?Apply frequent pressure relief in bed/chair?Avoid sun burn/scalds?Maintain a regular bowel program?A well balanced diet and adequate fluid intake?Compliance with medications?If you have an indwelling catheter, keep the tubing free of kinks, keep the drainage bags empty, check daily for grits (deposits) inside of the catheter?If you are on an intermittent catheterization program, catheterize yourself as often as necessary to prevent overfilling.?Carry an intermittent catheter kit when you are away from home?Perform routine skin assessments (NSCIA)DEMOGRAPHICS OF DIAGNOSISAGE RANGEThe risk of spinal cord injuries is at the highest between the ages of 16 and 30. Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65, while falls cause most injuries in older adults (Mayo Clinic).PREMORBID CONTRIBUTING FACTORS“In individuals with cervical SCI, respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation (Wong).”Depression affects different people in different ways but can be debilitating to all. Depression can lead to feelings of hopelessness which can lead to thoughts of suicide; the risk for suicide in SCI clients is most in the first 5 years. “It involves major changes in mood, outlook, ambition, problem solving, activity level and bodily processes, such as sleep, energy and appetite”. Other risk factors associated with depression include drug and alcohol dependence, lack of a family support, access to weapons and a previous attempt at suicide. C4 & C5 spinal cord injuries can affect a person’s self-esteem and feelings of self worth because they have to depend on people around them for almost everything, this can also lead to anxiety and depression (Reeve Foundation).GENDER “Spinal cord injuries affect a disproportionate amount of men. In fact, females account for only about 20 percent of traumatic spinal cord injuries in the United States (Mayo Clinic).”GENETIC INFLUENCES“Genetic variation may partially underlie complex personality and physiological traits—such as impulsivity, risk taking and stress response—as well as a substantial proportion of vulnerability to addictive diseases (Kreek),” which can all be contributing factors to accidents that result in SCI.OTHERTest and Diagnosis?X-rays. Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine. ?Computerized tomography (CT) scans. A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems. ?Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. A few days after injury, when some of the swelling may have subsided, your doctor will conduct a neurological exam to determine the level and completeness of your injury. This involves testing your muscle strength and your ability to sense light touch and a pinprick (Mayo Clinic).TREATMENT TEAM PROFESSIONPROFESSIONAL ROLE ON THE TEAM WITH THIS DIAGNOSISOccupational TherapistEducate client and their family on his or her condition, in this case SCI. During the initial stages of rehabilitation, OT practitioners will focus their treatment on regaining or maintaining the skills affected by the spinal cord injury, as well as maintaining and strengthening what muscle function the client has left. Educated and teaching their client’s on adaptive equipment that can make doing everyday tasks easier (Mayo Clinic). · Increasing independence in dressing, grooming, hygiene, feeding, and homemaking skills · Increasing the strength and function of your upper body and arms · Improving your thinking, visual, and perception skills · Evaluating and training in the safest method of bathroom transfers · Evaluating and training in computer skills (Rehab Team Site)Physical TherapistThe Physical Therapist is often thought of as a specialist in ambulation or independent movement. Although ambulation may not be an unrealistic goal, your physical therapist can help you meet other functional, short-term goals as well, such as: · Increasing your upper and lower body strength · Improving your balance · Obtaining maximum independence with a manual and/or motorized wheelchair · Obtaining maximum independence with bed mobility and basic transfers (Rehab Team Site)Rehabilitation NurseA nurse can assist the OT practitioner by helping them monitor the ventilator during OT treatment. Maintenance of any other tubes the client is hooked up to such as a feeding tube, GI tube, etc….Administer medications (Rehab Team Site)The Psychology DepartmentProvides services to you and members of your family who are learning to cope with the effects of your disability. When illness or trauma causes changes in levels of function and lifestyles, support and positive motivation are crucial to a successful adjustment by you and your family. You may meet with a member of the psychology department several times a week, in individual or group sessions. Services provided by the psychology department include: · Initial cognitive and emotional evaluation, as well as neuropsychological testing · Individual and/or group psychotherapy to facilitate your involvement in the rehabilitation process, your adjustment to your injury or disability, and the alteration in your physical, cognitive, and emotional functioning. · Marital, significant other and family therapy that focuses on changes in family dynamics caused by illness, trauma, and/or disability, as well as sexual counseling · Biofeedback and relaxation techniques (Rehab Team Site)DietitianTo address how the client’s diet needs to be in compliance with any tubes they may have to be on, educate family and caregivers (Rehab Team Site)Speech TherapistPerform assessments and provide treatment for swallowing, motor speech, voice, cognitive-communication disorders that result from the spinal cord injury and/or co-occurring brain injuries (Brougham).Recreational TherapistWill focus on leisure activities, hobbies, and crafts that integrate goals and functional tasks begun in other therapies. An integral part of therapeutic recreation is the community re-entry program, which consists of outings into the community, movies, shopping malls, etc. These outings provide an opportunity for you to apply techniques learned during therapy sessions and reach your maximum level of independence in the "real world." Family members are invited and encouraged to participate in the community re-entry program (Rehab Team Site).Respiratory TherapistWill work with client on breathing exercises to improve vital capacity so the risk of going to a ventilator decreases. Assist in removing any fluids that the client is unable to cough up (Brougham).The Discharge PlannerThis may be a social worker or case manager, is a vital member of your rehabilitation team. She/he will assist you with many aspects of your care, such as preparing and implementing your discharge plan, arranging meetings with you and your family, arranging a schedule for family observation and training days, working with other interdisciplinary team members, and working with your insurance carrier to communicate the rehab team's short and long term goals. Your case manager will also arrange any equipment and/or home modifications that may be necessary (Rehab Team Site).DoctorEmergency personnel typically immobilize the spine as gently and quickly as possible using a rigid neck collar and a rigid carrying board, which they'll use to transport you to the hospital. Early (acute) stages of treatment. In the emergency room, doctors focus on: Maintaining your ability to breathe Preventing shock Immobilizing your neck to prevent further spinal cord damage Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and formation of deep vein blood clots in the extremities (mayo clinic) Physician will also conduct x-rays, CT Scans and MRI’s as needed for further evaluation.FRAMES OF REFERENCES AND MODELS OF PRACTICE (I USED CONDITIONS AND PHYSICAL DYSFUNCTION BOOK)FORsMOPsFORSSYNOPSISMOPsSYNOPSISBiomechanical“Addresses the capacity for motion with specific relation to function; applying the mechanical principles of kinetics to movement of the human body and particular activities or functionsROM, Strength, Endurance -involved only if they believed the limitation in capacity affects the individual’s ability to do their occupations (Early 2014).”Model of Rehabilitation“The Model of Rehabilitation for Spinal Cord Injury is patient centered, based on the bestavailable evidence and aims to achieve consistency of practice, equity of access andsustainability of spinal cord injury services (Early 2014).”Rehabilitative“To enable the client to participate fully in daily living, work, and leisure activities using compensatory methods, assistive devices, and environmental modifications (Atchison).”Client-Centered or Person-Centered practice“We measure the effectiveness of person-centered services through the rightblend of measures, indicators, and questions such as the Personal Outcome Measures?. CQL guidesorganizations and communities in the development of person-centered services (CQL).”Refers to understanding the client's desires and wishes for intervention and outcome.Injury prevention and control“To increase the probability of preventing SCI in the future, substantial evidence demonstrates the importance of understanding prevention (Atchison 2012).”Model of Human OccupationMOHO“Seeks to explain the complex interactions between person, activity or occupation and environment.-Volition= motivation-Habituation= routines/customary-Personal Capacity=”ability for doing things” (Early 2014).”Compensatory “The Compensatory frame of reference allows for adjustments to be made to the way in which an activity is done, either through the method, materials or environment, to make certain that the occupation is completed by any possible means. When used with a rehabilitative approach, functioning is assessed and intervention modified as the condition progresses, and allows for the use of adaptive equipment to overcome the deficits the individual may have to increase wellbeing and independence (CookingMamas).”Occupational Adaptation“The occupational adaptation practice model emphasizes the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery. Practice based on occupational adaptation differs from treatment that focuses on acquisition of functional skills because the practice model directs occupational therapy interventions toward the patient's internal processes and how such processes are facilitated to improve occupational functioning. The occupational adaptation practice model is holistic (Schultz).”Learning Frame of Reference‘The Learning frame of reference used with an educative approach may be used to provide the teaching of new behaviors, information about and strategies of managing the symptoms of a disease or impairment (CookingMamas).”EVALUATION METHODSSTANDARDIZEDNAMEModified Ashworth Scale (MAS)COSTFreeRESOURCE spasticity in patients with lesions of the Central Nervous SystemSimilar to Ashworth, but adds a 1+ scoring category to indicate resistance through less than half of the movement. Thus scores range from 0-4, with 6 choices (Bohannon & Smith, 1987)Score Ashworth Scale (1964) Modified Ashworth Scale Bohannon & Smith (1987) 0 (0) No increase in tone No increase in muscle tone 1 (1) Slight increase in tone giving a catch when the limb was moved in flexion or extension Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension1+ (2) Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement)2 (3) More marked increase in tone but limb easily flexedMore marked increase in muscle tone through most of the ROM, but affected part(s) easily moved3 (4) Considerable increase in tone - passive movement difficultConsiderable increase in muscle tone passive, movement difficult4 (5) Limb rigid in flexion or extensionAffected part(s) rigid in flexion or extensionNAMEFunctional Independence Measure (FIM)COSTNot FreeRESOURCE“Provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps; measures the level of a patient's disability and indicates how much assistance is required for the individual to carry out activities of daily living (Rehab Measures).” Contains 18 items composed of:?13 motor tasks?5 cognitive tasks (considered basic activities of daily living)?Tasks are rated on a 7 point ordinal scale that ranges from total assistance (or complete dependence) to complete independence?Scores range from 18 (lowest) to 126 (highest) indicating level of function?Scores are generally rated at admission and discharge?Dimensions assessed include:?Eating?Grooming?Bathing?Upper body dressing?Lower body dressing?Toileting?Bladder management?Bowel management?Bed to chair transfer?Toilet transfer?Shower transfer?Locomotion (ambulatory or wheelchair level)?Stairs?Cognitive comprehension?Expression?Social interaction?Problem solving?MemoryNAMESpinal Cord Independence Measure (SCIM)COSTFreeRESOURCE in overall ADL function19 items assesses 3 domains:?Self-care (6 items, scores range from 0-20):?Feeding ?Bathing ?Dressing?Grooming?Respiration and sphincter management (4 items, scores range from 0-40)?Respiration?Bladder management?Bowel management?Use of toilet?Mobility (9 items, scores range from 0-40?Tasks in the room and toilet?Tasks indoors and outdoors ?The total SCIM scores range from 0 to 100?The original SCIM was revised to address substandard reproducibility (< 80%, Kappa = 0.66-0.73) of bathing, dressing, bowel management and mobility in bed, resulting in the SCIM II (Catz, et al. 2001)?The SCIM II had been analyzed statistically through Rasch modeling and clinically through expert opinion, the result leading to the SCIM III (Itzkovich, et al. 2007) NAMEQuadriplegia Index of Function (QIF)COSTFreeRESOURCE ADL's performed with the hands among non-ambulatory individuals with cervical SCI. The Quadriplegia Index of Function (QIF) was developed because Barthel Index was found to be insensitive to small functional gains made by tetraplegics during rehabilitation. ?The QIF can be administered by interview or observation?The QIF is assesses 10 ADL's: ?Transfers?Grooming?Bathing?Dressing?Feeding?Mobility?Bed activities?Bladder program?Bowel program?Understanding of Personal care?Each motor task is scored from 0 to 4 in order of increasing independence. The bladder and bowel program have separate sets of scoring criteria?The maximal total score of 200 added from the functional categories (180 points) and personal care (20 points) is divided by 2 for a score out of 100 points.?Each category score is weighted to contributes a different percentage to the total score. NON-STANDARDIZEDNAMENeuroimagingCOSTCost RangesRESOURCE Resonance Imaging was judged to be the neuroimaging modality of choice for assessment of SCI because of its ability to define location of injury, degree of cord compression, as well as presence of hemorrhage, contusions or edema.MRI-Diffusion Weighted Imaging is used to quantify the extent of axon loss after SCI.Functional MRI shows the correlation between sensorimotor activities of persons with chronic SCI with imaging of metabolic activities of brain and spinal cord.Magnetic Resonance Spectroscopy assess biochemical characteristics of the spinal cord after injuryNAMEMMTCOSTFreeRESOURCE of a person’s muscle strength, or ability of the muscle to move a part of the body against resistance. A doctor or therapist will assess muscle strength in individual muscles, and the results show which muscles are weak and the pattern of the weakness.NAMEObservation/ScreeningCOST15 mins billable to insuranceRESOURCEEarly, M. B. (2006). Spinal Cord Injury. In Physical dysfunction practice skills for the occupational therapy assistant (3rd ed., pp. 59-61). St. Louis, Mo: Mosby Elsevier.SUMMARY “A skilled clinician relies heavily on structured and unstructured observations of the client during the interview, evaluation, and treatment. By carefully watching, looking, and seeing, the practitioner learns much about the client’s functioning during unstructured observation. Consider what can be learned by observing clients during the evaluation…the OT practitioner uses structured observations as well to evaluate performance of self-care, home management, mobility and transferring. Done by having the client perform real tasks in real or simulated environments. Data from these observations yield information about the client’s level of independence, speed, skill, and need for special equipment and the feasibility for further training (Early).NAMEInterviewCOST15 minutes billable to insuranceRESOURCEEarly, M. B. (2006). Spinal Cord Injury. In Physical dysfunction practice skills for the occupational therapy assistant (3rd ed., pp. 58-59)). St. Louis, Mo: Mosby Elsevier.SUMMARY“An occupation-centered interview consists of asking client or family member questions relating to occupational habits and life roles, family situation, home setup, interest, values, and/or therapy goals. The OT gathers information on how clients perceive their life roles, physical dysfunction, health care needs, and therapy goals. (Early).”OCCUPATIONAL PERFORMANCE IMPACT (use Figure 4-5, pp. 69-71 as a guide)OCCUPATIONAL PROFILEMr. G, is a 30 yr. old Caucasian man who sustained a C5 complete SCI as a result of a MVA. As a result of his injury he is now tetraplegia with little functional movement. He is married with two young children and they live in the city in a one story brick house. He wife now assumes the role main homemaker and caregiver of their children. He assists where he can. He graduated from ITT with a master’s degree in computer software engineering. He was active before the accident with no prior health problems and a clean bill of health at his annual physical. Mr. G was referred to OT on the day of his injury and initially evaluated in ICU within 24 hours of injury. He was immobilized in cervical traction and his vital capacity stabilized after being on a ventilator for 24 hours, he also has compression garments on his legs to prevent DVT. He has no sensation in his LE, trunk, hands and wrist, as well as absence of elbow extension and pronation. He can assist in some ADL’s, communication and wheelchair mobility with supervision and setup but is total assist in all other aspects of life. Movements possible are shoulder flexion, abduction, and extension; elbow flexion and supination; scapular adduction and abduction. He has a weakened vital capacity due to paralysis of intercostals and may require assist to clear secretions. OT treatment objectives included (1) educating the client and family members of safety precautions and adaptive equipment that may be helpful (2) maintaining the movements in the UE’s that the client does have function of (3) achieving optimal independence in available musculature (4) achieving independent wheelchair mobility on all indoor and outdoor surfaces (5) receiving appropriate durable medical equipment (DME) to meet both short-and-long-term needs (e.g., manual and power wheelchair, cushion, and bathing and toileting equipment (6) returning to safe and accessible housing. Mr. G has had a difficult that accepting he has complete SCI. He could not imagine how his life was going to be okay now that he is a tetraplegic, his wife and children do give him some motivation and keep his life meaningful. He went to a psychologist once a week for a couple months to help him cope with his dysfunction and depression. He also stressed the importance of reading but states he does not have enough endurance or strength to hold a book for long periods of time. On discharge, He is doing better although he still gets sad from time to time. He is happy that OT has helped him find ways to maintain working so he can still support his family and with the help of OT he can assist his wife in helping him in dressing, hygiene, grooming and self-feeding. He can also now get around using a wheelchair. ANALYSIS OF OCCUPATIONAL PERFORMANCEADLSC4: require 24 hour caregiver assistance for all activities of daily living, although adaptive feeding and grooming devices are available but because of their setup and tendency to be time consuming and exhausting for a person at this level and will not usually result in task independence they usually don not benefit as much as hassle.(Atchison).C5: May require 24 hour caregiver assistance for activities of daily living, a generally strong person with a C5 may assist with some dressing, hygiene and grooming activities with the aid of assistive equipment. Feeding is generally possible with the use of adapted utensils and setup (Atchison).IADLSC4 & C5: task such as household maintenance, meal preparation, shopping, cleaning, clothing care and safety procedures will require assistance with all of these activities…taking care of others is particularly difficult, of especially if the injured person was the primary caregiver for a child, spouse, or parent. A concurrent goal of OT may be activities, such as diapering a baby or bathing a child that can allow them to resume some premorbid roles. Often, many these previous responsibilities must be delegated to others, when this happens it is important that the person with the SCI retain the responsibility for the verbal directions of care (Early 2014, Atchison 2012)WORKC4 & C5: with these levels of SCI, returning to work is usually not possible. However with proper high-tech devices, they could work from home if the resources are available. Remember that legislation mandates that work sites be accessible within reason, so a person with an incomplete SCI may be able to have arrangements made. Volunteering for an organization may also add some extra meaning to the lives of a person with a SCI. Due to the fact that the age at risk of SCI’s is so young; returning to work may be an important client factor. Teaching your client ways of how they can still feel like they are providing for their families and increasing their self-esteem and self-image is important, this is where the high-tech devices come into play, and working from home can be made possible (Early 2014, Atchison 2012).LEISURE C4: leisure participation and exploration will be difficult at this level because of the type of paralysis, however with the use of assistive devices (mouth stick, high tech computer equipment) leisure activities such as reading or playing computer games or watching TV can be possible. C5: at this level sensation of the UE is typically present, however diminished. Therefore a person may be able to participate in more of the leisure activities they had before the injury, just in adapted ways and exploring new leisure activities that are more geared toward their injury is an important key. As the same with level C4, mouth sticks, high tech computer equipment can be used to aid in this (Early 2014, Atchison 2012).EDUCATIONC4 & C5: depending on the level of injury, secondary diagnosis, complications, availability of specialty hospital resources, people with SCI can generally resume educational activities, even while still inpatients in rehab facilities. Adaptive writing devices, page turners, recording devices, and computers play an intricate part in being able to resume educational pursuits after the injury (Atchison). Cognition will typically still be present; therefore being able to continue their educational pursuits can increase their outlook on life, especially if he or she is young. SOCIAL INTERACTIONC4 & C5: Social interaction and participation will be impacted in those with SCI, especially because as a result of the injury they may feel embarrassed and have deceased self-esteem in social situations. Family support and support groups, where they can identify with others is munity Mobility: with a strong C5 SCI, driving with assistive devices can be possible. For C4 or low C5 total assist with transportation is required, such as attendant-operated van or accessible public transportation (Early 2014, Atchison 2012).PERFORMANCE SKILLSMOTOR SKILLSC4: impaired balance due to the extent of paralysis due to this level of injury, mobility is impacted due to paralysis of the LE, however with a power recline and/or tilt wheelchair with head, chin, or breath control and manual recliner, the person can be independent. Keep in mind that breathing strength is compromised in this level of injury. Posture will be dependent on bed, wheelchair and slings, assistive devices to keep posture maintained. During bed mobility, total assist with a full electric hospital bed with Trendelenburg feature and side rails is indicated. Coordination is impacted due to level of injury as well as strength because the person has lost most all sensation. It is important to keep neck muscles from becoming stiff, as those muscles are the few that will be movable. Endurance and energy will be impacted due to respiratory complications associated with this level of injury (Early 2014, Atchison 2012).C5: a person with this level of injury will have a few more movements than that of a C4 injury; however function is still greatly impaired. Due to the lower extremities being paralyzed and the upper extremities being weak, balance will still be impaired. Unlike with the C4 level injury, a person with this level can operate a manual wheelchair independently to some assist indoors, on noncarpeted, level surface and some to total assist outdoors. A power wheelchair can be operated independently. During bed mobility some assist is required with a full electric hospital bed with Trendelenburg feature with patient controls is indicated. Postural support devices needed. Working on building strength in the UE is important, so that person can assist in some Areas of Occupations. Endurance and energy are going to be impacted much of the same way as in the C4 level SCI (Early 2014, Atchison 2012).PROCESS SKILLSC4 & C5: organizing space and objects to best benefit the person with the injury is important. Adapted equipment can be helpful in this as well as DE cluttering the main areas that the person will be using. In the case of C4, once they wake up from being on a vent, their temporal organization may be impacted as well as their energy level. Initially, ask them basic questions until they are more stable. Cognition is usually intact in SCI patients. With C5 SCI, their ability to problem solve may be a useful took in aiding their rehabilitation (Early 2014, Atchison 2012).COMMUNICATION/INTERACTION SKILLSC4 & C5: Total Assist to independent depending on work station setup and equipment available (ex. Use of mouth stick, high-tech computer access, environmental control unit)Able to instruct in all aspects of care, for themselves and family, even if they cannot physically do the task themselves. This can be important for maintaining some self-identity and control (Early 2014, Atchison 2012).PERFORMANCE PATTERNSHABITSC4: all habits impacted, such as brushing teeth or bathing independentlyC5: may be able to assist in habits done prior to injury, in adapted ways.ROUTINESC4 & C5: due to the extent of the c4 and c5 SCI, routines previously followed will be impacted. Bathroom routines as well as self-feeding are impacted. When once the person could handle the routines of ADL’s, the paralysis caused by SCI will now require that they have total assistance in most of these areas. This is in part due to the loss of sensation, strength, balance, being bed ridden. These patients will have tubes for emptying the bowel and bladder (Early 2014, Atchison 2012).ROLESC4 & C5: due to the extent of injury the client’s roles such as father, homemaker, and spouse are impacted. Learning to accept this can be difficult and often leads to depression. Being able to get back to functioning in the roles they once had is an important goal in OT intervention, although with these levels of SCI that can be a challenge (Early 2014, Atchison 2012).CONTEXTSCharacteristics of the meaning of context in recapturing self-care: a) support from others, b) expectations in the air, c) extended time, d) new daily structure, e) therapeutic relationship enabling possibility, and f) gradual change in challenge (Early 2014).CLIENT FACTORSValues, Beliefs, and Spirituality are impacted, when a SCI occurs a person’s whole world and view on their selves can change. It is important that they see the meaning and purpose of things beyond themselves. Important to keep motivation since all aspects of their lives are impacted. Body Structures will be weakened such as, sensory (due to paralysis), Neuromusculoskeletal (due to high level of injury), Cardiovascular (spinal shock), Voice and Speech (due to low endurance and energy and diaphragm strength), Skin (increased risk of ulcers) which is turn can impact the healing process and what function they have left. Body Structures are impacted such as, the spinal cord (where the injury is located), voice and speech, the heart and lungs, immune system, digestive, reproductive, bones and joint become weak from misuse, skin and sensory issues can occur due from lack of movement. THIS NEXT SECTION (Body Functions) CAME FROM MY THOUGHT PROCESSES FROM BOTH THE PHYSICAL DYSFUNCTION AND CONDITIONS BOOKBODY FUNCTIONSGLOBAL MENTAL Mental capacity is still intact, however depression and lack of motivation can arise in people with this level of SCI. Psychological state should be addressed.SPECIFIC MENTALIn these levels of SCI, lack of sensation can lead to secondary disabling conditions and pain in places where some sensation is left, so safety should always be considered. Memory, mental capacity, cognition usually intact. Can remember how to function in task but due to injury physically being able to complete them is hard without assistance. SENSORYDue to paralysis, decreased sensory input in extremities can put patient in at risk for a number of comorbid conditions.HEARING/VESTIBULARHearing/Vestibular usually intactSENSATIONSDue to lack of sensation thermal regulation is another function that can be disturbed after SCI. Poikilothermic, which is a complication occurring the first year after the injury where the body assumes the temperature of the external environment. This can lead to discomfort and the bodies’ ability to conserve body heat, which puts the body at risk for hypothermia. Extreme temperatures should be avoided and attention should be given to the extent and type of clothing worn by the client at all times (Atchison). The risk of Postural Hypotension and DVT should also be noted during OT therapy. Both of these conditions result in cervical and thoracic SCI due to the reduced muscle tone in the legs and trunk. Decreased blood pressure results in postural hypotension can be prevented by the use of antiembolism hosieries and abdominal binders, which externally assist circulation. Symptoms include lightheadedness, dizziness, pallor, sudden weakness, and unresponsiveness. Client should be semi reclined or reclined potion should be maintained until symptoms subside. Deep Vein Thrombosis causes embolisms and can be life threatening if not detected. Clients at most risk for this 2 weeks post injury, however it remains a concern in higher SCI’s due to extent of paralysis. Signs of DVT are swelling in the LE’s, localized redness, and a low-grade fever.PAINPain can be associated with lingering sensations in some areas of body. Pain from ulcers and sores, autonomic dysreflexia, tubes, increased risk of injuring extremities due to paralysis.NEUROMUSCULAR/ MOVEMENT RELATEDROM, Strength, Endurance, Spasticity, Swallowing, among others is negatively impacted. Skin integrity is at risk from lack of movement. Almost all movement patterns are impacted with this level of SCI.CARDIOVASCULARHeart rate and blood pressure can get to dangerous levels due to extent of SCI.RESPIRATORYThe diaphragm is weakened, therefore respiration, inspiration, breathing strength are impacted due to paralysis of intercostal.C4: May be ventilator free, if not two vents should be available(beside and portable), as well as suction equipment due to lack of cough reflex, generators and battery backup should also be available in case of emergency.C5: low endurance and vital capacity caused by paralysis of intercostals: may require assist to clear secretions. This can make talking for extended periods of time difficult. VOICE AND SPEECHCommunication devices can serve as an aid when talking becomes taxing due to decreased endurance or choking hazard because of inability to cough up secretions. SKINAt increased risk for skin breakdown such as ulcers, sores, pain from disuse, secondary disabling conditions.ASSETSC4: neck flexion, extension, rotation; scapular elevation; inspirationC5: shoulder flexion, abduction and extension; elbow flexion and supination; scapular adduction and abductionPROBLEMS REQUIRING OTC4: paralysis of trunk, UE, LE; inability to cough, endurance, and respiratory reserve low secondary to paralysis of intercostals. FIM: 28/assist=12C5: absence of elbow extension, pronation, all wrist and hand movement; total paralysis of trunk and LE. FIM: 41/assist=35TREATMENT PLAN FUNCTIONAL PROBLEMDecreased ability to assist with dressing LONG TERM GOALPerform upper body dressing with min. assist within 2 months.INTERVENTIONSSHORT TERM GOAL 1Don pull-over shirt with mod. assist while seated with max trunk support for 3/5 attempts three times a week for 1 month, to increase level of independence with dressingEducate client on proper techniques they can use to make donning and doffing shirt easier for them. Give your client worksheets with diagrams of these that they can refer back to. Include assistive devices into the activities such as a dressing stick and universal cuff to assist in the added ROM needed and to support the stick on hand since hand function is gone and instruct them to buy clothes a size too big.SHORT TERM GOAL 2Don pull-over shirt with min. assist while seated with max trunk support for 5/5 attempts three times a week for 1 month, to increase level of independence with dressingHave an activity that stimulates reaching up in air as to put on a shirt. Tape objects to wall and while maintaining max truck support and safety, have them reach up to item to maintain ROM in shoulder and elbow.FUNCTIONAL PROBLEMInability to self-feed LONG TERM GOALClient will improve in ability to self-feed using assistive devices by discharge dateINTERVENTIONSSHORT TERM GOAL 1Client will use adaptive eating utensils with max trunk support twice a week for 2 weeks with mod fatigue, to increase level of independence during self-feeding.Client simulate the act of bringing food to mouth using a adapted eating utensil with an extended handle and a universal cuff to aid in holding the utensil, once they have achieved needed ROM for doing this task, add food to utensils or try graded up the activity.SHORT TERM GOAL 2Client will use adaptive eating utensils with max trunk support twice a day for 1 month with min fatigue, to increase level of independence during self-feeding until discharge date.Client will use arm weights while doing elbow flexion activities to increase strength and endurance while self-feeding (bringing hand to mouth).FUNCTIONAL PROBLEMUnable to participate in leisure activitiesLONG TERM GOALClient will be able to use a mouth stick to aid in leisure activities by discharge dateINTERVENTIONSSHORT TERM GOAL 1Client will be able to use a mouth stick independently with setup and supervision with max truck support to read a book during 1 month of therapy.Educate the client and family on proper positioning of bed or chair to maximize safety and trunk support while performing activity.SHORT TERM GOAL 2Client will be able to play computer games using a mouth stick and stylus independently with setup and supervision with max truck support whenever appropriate by discharge date.Conduct ROM neck exercises to maintain neck movement and decrease stiffness. Also while they do these exercises you can add some sensory stimulation by adding music, especially a genre they liked before the injury.FUNCTIONAL PROBLEMUnable to participate in grooming activitiesLONG TERM GOALClient will be able to participate in grooming activities with min assist (setup and supervision) in 4 weeks.INTERVENTIONSSHORT TERM GOAL 1Client will be able to brush teeth independently with mod assist using an extended handle and universal cuff with setup and supervision with max trunk support twice a day after 2 weeks.Place 2 pound wrist weights on client and instruct them to bring arms to chest for 5 repetitions. Grade the activity as client’s strength improves, this is a purposeful activity that simulates the motion needed for brushing their teeth.SHORT TERM GOAL 2Client will be able to comb hair independently with min assist using an extended handle and universal cuff with setup and supervision with max truck support once a day after 2 weeks.Have client simulate doing jumping jacks with max truck support and supervision to increase ROM in shoulders and elbows.Discharge PlanIndications that client is ready for discharge●Patient activity level and functional status improve enough for safely being discharged from OT services or OT services are no longer helpful.●The nature of the patient's current home and suitability for the patient's conditions (eg, presence of stairways, cleanliness)●Availability of family or companion support●Ability to obtain medications and services●Availability of transportation from hospital to home and for follow-up visits with OT or other healthcare professionals●Availability of services in the community to assist the patient with ongoing care●Obtain and self-administer medications●Perform self-care activities(with assistance)●Eat an appropriate diet or otherwise manage nutritional needs●Follow-up with designated providers and being discharged to another type of rehabilitation settingTypes of Discharge environments the client may be referred toHomeHome Health Skilled Nursing Facility(SNF)Rehabilitation ClinicOutpatient TherapyInpatient Rehabilitation SynopsisI felt this project was beneficial. Although we only had one dysfunction to concentrate on, in the future if we need some information on other dysfunction we have our classmate’s information to go back and look at. I thought the lay out of the project was extremely good as well as the hints scattered about to help us locate some of the information. I don’t know about other people but for me the goals section was tough, it was hard to come up with goals when the client has little function anywhere so I hope mine are adequate. I tried to think outside the box and considered if they had some movements but still no use of hands or arms could they still do activities, the chapter on SCI in the book lead me to believe they could with a lot of assistance. I also targeted my goals to a stronger person with C5 SCI if that makes sense. The chapter in our Physical Dysfunction book and Conditions book on SCI was highly beneficial to me. Of course these projects are time consuming and of course I am somewhat of a procrastinator so I can see how they could be extremely difficult and stressful, I was proud of myself that I didn’t wait until last minute to do the majority of it and took my time and did the it to the best of my ability. ReferencesAlper, E. (2014, May 15). Hospital discharge. Retrieved July 10, 2014, from , R. (2011, March). Speech-language pathology treatment time during inpatient spinal cord injury rehabilitation: the SCIRehab project. Retrieved June 21, 2014, from ., & Dirette,?D.?K. (2012). Spinal Cord Injury. In Conditions in Occupational Therapy (4th?ed., pp.?257-281). Baltimore, MD: Lippincott Williams & Wilkens. Cooking Mamas. (n.d.). Frames of Reference | Cooking MamaS. Retrieved July 5, 2014, from Council on Quality and Leadership. (2010). Principles and Practices in Person-Centered Services. Retrieved?July 5, 2014, from . (2006). Spinal Cord Injury. In Physical dysfunction practice skills for the occupational therapy assistant (3rd?ed., pp.?534-556). St. Louis, Mo: Mosby Elsevier. Johns Hopkins Medicine Health Library. (2014). Acute Spinal Cord Injury. Retrieved?June?22, 2014, from . (2005, October 26). Genetic influences on impulsivity, risk taking, stress responsivity and vulnerability to drug abuse and addiction. Retrieved?July?5, 2014, from neuro/journal/v8/n11/full/nn1583.htmlMayo Clinic Staff. (2014). Spinal cord injury Definition - Diseases and Conditions - Mayo Clinic. Retrieved?July?5, 2014, from . (2014). Spinal Cord Injury: Treatments and Rehabilitation Symptoms, Causes, Treatment. Retrieved?June?21, 2014, from Spinal Cord Injury Statistical Center,. (2012, February). Spinal Cord Injury Facts and Figures at a Glance. Retrieved?June?28, 2014, from . (2011). What is autonomic dysreflexia. Retrieved?June?21, 2014, from . (2010, August). Outcome Measures in Spinal Cord Injury. Retrieved?July?5, 2014, from Foundation. (2014). Depression-Spinal Cord Injury - Paralysis Resource Center. Retrieved?July?5, 2014, from Team Site. (2009). Spinal cord injury rehab team. Retrieved?July?5, 2014, from Institute of Chicago. (2010). Rehabilitation Measures database. Retrieved?July?5, 2014, from Measure Database. (2014, May 28). Rehab Measures - Functional Independence Measure. Retrieved?June?28, 2014, from , S. (1992). Occupational adaptation: toward a holistic a... [Am J Occup Ther. 1992] - PubMed - NCBI. Retrieved June 28, 2014, from Center. (2014). Levels of Injury - Understanding Spinal Cord Injury. Retrieved?July?5, 2014, from Rehabilitation Clinical Network. (2012, February). Model of Rehabilitation for Spinal Cord Injury. Retrieved?July?5, 2014, from ., Shem,?K., & Crew,?J. (2012). Specialized Respiratory Management for Acute Cervical Spinal Cord Injury. Retrieved?July?5, 2014, from ................
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