Presentation on theme: "Exploration of Function and Identity after SCI"— Presentation transcript:
1Exploration of Function and Identity after SCI Raheleh Tschoepe MS, OT/LUNC Health CareInpatient Rehabilitation UnitSCI TeamNovember 3, 2012RahelehHandout:slidesLevelsPadding/positioningSCI Educational Resources
2ObjectivesBy the end of this session, you will have basic understanding of:Incidence and etiology of SCI in the U.S.SCI injury levels, syndromes and the ASIA Classification System – what do they tell us?How an interdisciplinary therapy team can maximize functional independenceHow to recognize, prevent and address potential barriers to progress across the continuum of careOT evaluation and treatment procedures, discharge planning and integration into interdisciplinary treatmentFunction and identity as guides to treatment planningRaheleh
3Statistics Incidence: 12,000 new cases each year Prevalence: ~265,000 persons in the U.S. living with SCIAge : years oldSince 2005: 40.7 years oldGender: 80.7 % reported have been male
5Neurological Levels Incomplete tetraplegia (39.5%) Complete paraplegia (22.1%)Incomplete paraplegia (21.7%)Complete tetraplegia (16.3%)ASIA A - No sensory or motor function is preserved in the sacral segments S4-S5No anal sensation or contractionASIA B - Sensory, but not motor, function is preserved below the neurological levelMust include the sacral segments S4-S5.ASIA C - Sensory or motor function is preserved in the S4/S5 segmentsMust have either:voluntary anal sphincter contractionsacral sensation plus sparing of motor function more than 3 levels below the motor levelMore than half of the muscle grades below the single neurological level are < 3ASIA D - Sensory or motor function is preserved in the S4-S5 segments.sparing or motor function more than 3 levels below the motor levelAt least half of muscle grades below the single neurological level are > or = 3ASIA E -Sensory and motor function are normalPersistent hyperreflexia does not negate this classification
6Length of stay and discharge Acute care daysInpatient Rehab – 37 days(greater for people with complete injuries)89.9% discharge to a private residence6.2% discharge to nursing homesIs it enough to discharge at a “supervision” level?
7More than a number…"I think a hero is an ordinary individual who finds strength to persevere and endure in spite of overwhelming obstacles. “ -Christopher Reeve
9Occupational Therapy Practice Framework Occupational therapy is:“..the application of an intervention process that facilitates engagement in occupation to support participation in life…”Occupational therapists and occupational therapy assistants:“focus on assisting people to engage in daily life activities that they find meaningful and purposeful.”
11OT’s RoleCarolyn Baum defines independence as the ability to take responsibility for one's own role performance, needs and desires. In order to acknowledge the variety of ways individuals accomplish the necessary and desirable tasks in their lives, it is essential to embrace a broad view.The profession recognizes independence as a state of self-determination.Baum, C. M. (2011). The John Stanley Coulter Memorial Lecture. Fulfilling the promise: Supporting participation in daily life. Archives of Physical Medicine and Rehabilitation, 92(2),Former 2-time AOTA president, president of the now National Board for Certificaiton in OT; Chair of Research Commission for AOTF
12OT’s Role applied to SCI Spinal cord injury or disease can lead to changes that are unanticipated, immediate and often permanent.Impairment or loss in motor, sensory functionResult is a wide range of limitations in activities and participation.Herrmann et al. (2011). The comprehensive ICF core sets for spinal cord injury from the perspective of occupational therapists: a worldwide validation study using the Delphi technique. Spinal Cord, 49,The ICFMaximizing abilities with CLOF – research articles
13International Classification of Functioning, Disability, and Health OT’s Role in SCIProblems are direct result of interaction between disease or injury sequelae and environmental and personal factors (contextual factors).Biopsychoscial modelof theInternational Classification of Functioning, Disability, and HealthICF provides common understanding and descriptive language and provides a universally accepted framework for describing functioning, disability and health in persons with all kinds of health conditions, including SCI.
14OT’s Role in SCI ICF component body functions * Temperament and personality functions* Energy and drive functions* Sleep functions* Vestibular functions* Sensory functions related to pain, temperature, other stimuli* Voice functions* Increased/decreased blood pressure* Mobility of joint functions* Control and coordination of voluntary movementIn 2011, there was a study performed to determine the validity of the ICF core sets for individuals with SCI in the early post-acute and long term context from perspective of OT’s.
15OT’s Role in SCI ICF component body structures * Cervical, thoracic and lumbosacral spinal cord* Cauda equina* Spinal nerves* Structure of eyes* Urinary system structure* Structure of UE, LE, trunk* Bones, joints, muscles, skin of entire body* Structure of head and neck* Structure of respiratory and intestinal systems
16OT’s Role in SCI ICF component activities and participation examples: * Religion and spirituality; socializing; political life* Using telecommunication devices* Changing basic body position* Transferring oneself* Pricking up, grasping, releasing manipulation* Driving* Washing body parts, drying oneself* Sexual relationships* Using household appliancesIn 2011, there was a study performed to determine the validity of the ICF core sets for individuals with SCI in the early post-acute and long term context from perspective of OT’s.
17OT’s Role in SCI ICF component environmental factor examples: * Food; drugs* General assistive products and technology for personal use in daily living, education, employment* Design, construction, and building products and technology for entering, exiting and gaining access to facilities* Financial assets* Immediate, extended family and friends* Acquaintances, peers, colleagues, community members
18Functional Recovery by Level Tetra vs. Para (C1-T1 vs. T2 and below) DEFINE QUADriplegia vs. PARAplegiaVent dependence at C1-C3 completeIncomplete vs. Complete; ASIA scale ASIA A-ASIA E: More detail next slideC7** Standard for where individuals can function independently (depending on obesity, age, cognition, proprioception, fear, culture, previous strength, athletic ability, motivation, adjustment to disability, pain, spasticity, fractures, medical complications).
19Barriers to Progress Spinal Shock Pressure Ulcers DVT & PE Spasticity – benefit or hindrance?Limited ROM ContracturesNeurological Shoulder: common in tetraplegiaHeterotopic Ossification (HO)OsteoporosisOrthostatic HypotensionSpinal shock – temporary loss of SC-mediated reflexes below the LOI: gradually resolves over days and monthsMaximize functional recovery and reduce LOS – each year, 1/3 to ½ of all ppl with SCI are readmittedPressure UlcersSignificant detterent to independent, productive and satisfying lives80% of SCI survivors have a PU during their lifetime; 30% have more than one; 95% are preventableEiotlogy: unrelieved pressure, sheer, friction, moisture, poor nutrition, immobility, psychological, social and economic factorsMost common areas of breakdown: Ischii, sacrum, coccyx, trochanters, heelsAVOID pressure and sheering and moisture build-upBladder ProgramsMost common infection in patients with spinal cord injuryAvoid indwelling foley catheters – puts people at risk long-term for bladder cancerStatistics on LOS and COSTLOS acute care 15 daysLOS AIR 44 daysInitial hosp costs after injury $140,000Avg. first year expenses for SCI $198,000Percent covered by private health insurance: 52%Average lifetime costs for paras - age 25; quads - $1.35 age 25Doctors can be distracted by medical issues and it’s important for ancillary staff to bring to light some of these issuesPRESSURE ULCERS:Blood pressureMedication to regulate and interaction betweenEncourage use of external modalities (TED hose, ace wrapping, Abdominal binder)Reinforcing OOB activity as EARLY as possibleFluid/food intakeBowel/Bladderd/c foley as soon as medically appropriate!Medication to regulateEncourage independence & compliance with B&B programs to minimize accidents and prevent ADEncourage commode use ASAPSpasticity Management
20Barriers to Progress Orthostatic Hypotension Autonomic Dysreflexia *Bladder Management*Bowel Program* Skin IssuesRespiratory illnessMost common cause of death is resp. failure.Head InjuryPsychosocial AdjustmentResp Care – primary cause of death with PE, septicimia
21OT Evaluation: ICF * Same as above Prior Level of Function* Body functions/Structures<>Activities<>Participation* Environmental factors, Personal FactorsCurrent level of function* Same as above* Musculoskeletal and neuromuscular assessment* Sensation (light touch, pin prick, proprioception)* Mobility (balance, synergy, coordination, substitution)* Skin integrity, blood pressure, endurance* Psychosocial factorsBiopsychosocial Model of ICFPrior Level of Functionassess baselineunderstand pt/family goalslearn about pts environment & resources & supportCurrent level of function (esp in acute will establish if neurologicaly they are recovering or getting much worse, this should be re-eval’d every week)Per ASIA examine – done in supine. Prevents interuptions due to orthostasis and provides a constant from Acute to inpat, sitting may cause them to focus more on balance than what you’re askingMMT, ROM, Tone, Neurological shoulder-which will be discussed in detail later-for now its important to:MMTNever assume that all musculature above the diagnosed level is functioning normally – you’ll miss any preexisting weakness and substitution patternsWhen performing a muscle test, watch for substitution – pts quickly learn to use functioning musculature to perform the actions of those that are weakened or absent, this is an important skill for improving functional status but it can wreak havoc on the eval results. Make sure to eliminate motions at all other joints- ex: ant deltoid can be used to extend the elbow in the absence of triceps functions- radial wrist extensors can be used to flex the fingers in the absence of any functioning finger flexors (tenodesis grasp)Sensation: ASIA testing – compare cheek with area testing – same or diminished, proprioception, pin prick (great predictor for motor recovery based on the location of the 2 tracts in the spinal cord, kinesthetics)Mobility (balance, muscular coordination, spasms)OrthostaticsEndurance
22Treatment along the continuum of care Working Together for a Successful Outcome: Interdisciplinary Concepts
23Interdisciplinary Concepts I/ADL Progression is inextricably linked to PT, RT, SLP, psychology, medicine and nursing concepts:- ADLs at a wheelchair levelDME/AE selectionMobility preparation and strategiesTransfers to BSC, TTB, shower chair, standard bed, couch, dining room chairBowel/bladder management (education & technique)Sexuality educationInstrumental Activities of Daily LivingClient’s ability to direct his/her careSCI EducationRahelehADL PROGRESSIONSitting balance on DMERolling for dressingDME/AE selectionTransfers to BSC, TTB,shower chair, standard bed5) ADLs at a wheelchair level (grooming, dressing, cathing)6) Bowel/bladder management (education & technique)7) Sexuality education
24Progressing ADL’s ADL Hallmark level/expected outcomes Intervention Tips/TricksEating/GroomigC5: set up with AEC6: set up with or without AE (Tenodesis)C7/C8: indep with time or AET1 and lower – indep-dorsal wrist support with u-cuff-univ cuff-non-skid material-long straw, cup with univ handle-built up handles and tenodesis-mobile arm support-wash mitt-electric toothbrush/razor- Automatic dispensers-upright positions with elbowssupported-Progress based on food consistency/type &preferred foods-C or D handles to maximize handling-lever handlesTenodesis
25ADL’s - Progression ADL Hallmark level/expected outcomes Intervention Tips/TricksBathingC5: max A to dependentC6: min to max A (Tenodesis)C7/C8: mod A to indepT1 and lower – indeplong handle spongeSoap on a ropeHand held shower headsGrab bars- wash mitt- electric toothbrush/razor- Automatic dispensers- Lever handlesCombine bathing/toileting tasksMonitor water temperature and blood pressureYou can see where principles of body mechanics, balance, coordination, proprioception, sensation are important in ADL’s
26ADL’s - Progression ADL Hallmark level/expected outcomes Intervention Tips/TricksDressingC5: mod A to dependentC6: mod I to max A (Tenodesis)C7/C8: mod IT1 and lower – indepButton/Zipper hookDressing sticks, sock aides, reacherLeg strapsBed ladderSupine in bed; Long sit; ring sit; rolling; in wheelchair (wc)Progress surface types (firm to soft)Progress body mechanicsBackwards/forwards chainingOver-practice to assure functional carry-overEncourage progression to wc level
27Bowel and Bladder Equipment Selection Do your homework and advocate Bowel and Bladder Equipment Selection Do your homework and advocate! Important considerations:BasicComplexTub Transfer Bench vs. Shower ChairTile in Space vs. ReclineStandard vs. BariatricCut out location/needDrop Arm vs. FixedWheeledPadding vs. Hard Surface
28Bladder Management Program type - UMN vs. LMN Adaptive Equipment Intermittent: bag kits, straight catheters, antibacterial, pre-lubricatedIndwelling: leg bag, Foley bag (aesthetics, modesty)Catheterization schedule: habits, roles, routinesKeys to success: consistency, hydration, activity, support systemAdaptive Equipmentmirrors, inserters, spreaders, holders, clothing/environmental modificationPositioningEducation
29Bowel Management Program type - UMN vs. LMN Schedule - habits, roles, routines- consistency, diet, activity, support systemDME/Adaptive Equipment- mirrors, inserters, stimulators, environmental modificationPositioning- bed vs. bedside commode vs. shower vs. standard toiletEducation
30Sexuality P-LI-SS-IT model PermissionLimited InformationSpecific Suggestions (OT’s STOP here)Intensive TherapyEducate on the facts & provide information on:adaptationpositioning for securitycomfort and trunk controlRefer to physician for potential medical interventionsTaylor, B. & Davis, S. (2006). Using the extended PLISSIT model to address sexual healthcare needs. Nov ; 21(11)Women – lubrication, orgasm, pregnancyMen – erection, ejaculation, fertilityUMN – lose psychogenic but retain reflexive erection abilityLMN – lose reflexive but may retain psychogenicPredictors of sexual satisf: perception of partner’s satisf with sexual relationship, intimacy of the relationship, willingness of sexual experimentationPsychological aspect – how the person perceives themselves as a sexual being – ROLES!!
31Another ADL: a relearning process – SexualitySCI may result in heightened, decreased, or lack of sensation and perception in various dermatomes.Encourage patients to:explore themselves physically and identify these changes, discuss with therapists and physicians when there are questionscommunicate changes with their partner and be open to multiple forms of sexual stimulation.Consider psychosocial history and current issues – refer as appropriate to other disciplinesAnother ADL: a relearning process –How does the person view their roles, responsibilities and participation?
32Management of the Neurological Shoulder Coordination of Muscle SynergiesSCI results in inability to coordinate isometric, eccentric, and concentric muscle contractionsSCI results in inability to control speed and directionAs a result, clinical presentation often shows “all or nothing”Upper extremity preservation/protectionBetz, Kendra. Contemporary Forums Spinal Cord Injury Conference: Upper Extremity Pain and Injury: Interdisciplinary Approaches for Prevention and Treatment. San Francisco, 2008.Neuromusc reeduc
33Aging & SCI Mental flexibility/adaptability Considerations for acute SCI in older adultsMental flexibility/adaptabilityPre-existing body structure/function issuesSupport systemsResources/ability to make modificationsConsiderations for older adults with chronic SCILife expectancy with paraplegia – similar to that of able bodied adults; tetraplegia – reduced by 10%Exacerbated musculoskeletal, respiratory, urinary symptomsMay benefit from more assistance, home modifications, AE/AD/DMEHarvey, L. (2008). Management of Spinal Cord InjuriesSkin, vision, mobilityUse of AD, AE, DME
34Applying what we know… “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” ~Maya Angelou
35HOW do we define function and independence? ROMStrengthFIM scores: ADL’s, transfers, mobilityInternational Classification of Functioning: “positive overall health condition”AOTA: Living Life to its FullestCLIENT GOALS“…a state of self determination.”
36WHO defines function and independence? John:40 year old OT with 15 years of SCI experience. Works 50 hours/week on an inpatient SCI unit.Melanie:20 year old in roll over MVC 2 weeks ago with resulting T10 ASIA A SCI.With so many treatment options, an infinite number of attainable goals – how do we prioritize?
37Therapy is… …an interactive, interpersonal experience. It is the therapist’s responsibility and skill to read between the linesHave we taken into account:Purpose, goals, routines, meaning, drive, desires, fears, world view, context, etc?
38Case Study - Jason 31 yo male, injured in bike racing accident IBM employeeRequired to d/c from AIR at modified independent levelHe blogged his entire rehab journey and continues to blog on a regular basisThe following are some quotes reflecting his rehab experience
39Lessons from a Rehab Blog Occupational Therapy“Occupational therapy teaches you how to do pretty much anything you need to do to live your life. Lately, whenever the therapists ask me to do something a normal person would do, like open a door or push an elevator button, I say, "It's occupational!". “Speaking of food, my occupational therapist, is going to teach me to make brownies on Friday. Ghirardelli brownies no less. Earlier this week, they taught me to make a bed, vacuum a carpet, and do laundry. All good stuff to know. All 10 times harder than it is for walkers.”
40Lessons from a rehab blog OT in context: Purpose/Meaning“Work is going about as well as it could. I'm still working 3 hours a day, and I think it's getting easier. I'm still glad I'm doing it. It makes me feel like I'm accomplishing something. It's about the only time I feel useful.”“Gus continues to make himself indispensable. Last weekend, we took my van over to his house to do a little work on it. I really appreciate that, but it's frustrating to watch him do work that I used to be perfectly capable of doing myself. Makes me feel useless.”
41Lessons from a rehab blog Independence gets a whole new meaning“……they say it means that I will eventually be able to regain almost complete independence. It's hard to imagine right now how I'm going to get to that point since right now, I can't even sit up on my own, but for now I'm willing to trust that it's true.”“I take solace in the fact that I've met people who have lived in chairs for decades, and they have obviously figured all this stuff out, but I'm still getting a little nervous about whether, and when I'll figure it all out.”
42Lessons from a rehab blog Reality of discharge, necessity of routine“That knowledge and my short countdown to release has me worried. There's still a LOT I can't do on my own. It's hard to imagine I'm going to master all of it in the next three weeks. I'm going to have to use some of those skills to survive in my apartment. Transferring from my wheelchair into the shower is just one example of a daily activity that requires a tremendous amount of strength and balance, and which has a lot of opportunity for painful failure. I've only done it once successfully, and the shower in here is much larger, and I had two spotters.”
43What it all means…Teamwork & communication through the continuum of care and stages of recovery impacts outcomesSuccess is dependent on a good foundationA good foundation is based on listening.Bio-psycho-social model indicates all 3 are critical and must all be investigated and integratedTherapists must facilitate development of a reliable, comfortable and patient-driven routine. Then practice, practice, practice.We bridge the gap from injury to recovery through training, education, and support…EMPOWERMENT
44References Harvey, L. (2008). Management of Spinal Cord Injuries Consortium for Spinal Cord Medicine. Preserving Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Paralyzed Veterans Association Available for free at:Lindsey L, Klebine P, Wells MJ. Understanding Spinal Cord Injury and Functional Goals. Birmingham, AL: Office of Research Services, University of Alabama at Birmingham, 2000.O’Sullivan S, Schmitz T. Physical Rehabilitation: Assessment and Treatment. Philadelphia: F.A. Davis Company, 2001.Somers, M. Functional Rehabilitation of Spinal Cord Injury. Norwalk, CT: Appleton & Lange, 2002.Musick, Darrell. Contemporary Forums Spinal Cord Injury Conference: Mobility Progression for Spinal Cord Injury. Las Vegas, 2006.Betz, Kendra. Contemporary Forums Spinal Cord Injury Conference: Upper Extremity Pain and Injury: Interdisciplinary Approaches for Prevention and Treatment. San Francisco, 2008.McKinley, W.,Santoa, K., Meade, M., Brooke, K., "Incidence and Outcomes of Spinal Cord Injury Clinical Synromes", The Journal of Spinal Cord Medicine, 30(3): , January 2007.Hutchinson, S., Loy, D., Kleiber, D., Dattilo, J., “Leisure as a Coping Resource: Variations in Coping with Traumatic Injury and Illness”, Leisure Sciences, 25: , 2003.O’Brian, A., Renwick, R., Yoshida, K., “Leisure participation for individuals living with acquired spinal cord injury”, International Journal of Rehabilitation Research, 31 (3), 2008.
45ReferencesOutcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals. Consortium for Spinal Cord Medicine: Clinical Practice Guidelines. July 1999Herrmann et al. (2011). The comprehensive ICF core sets for spinal cord injury from the perspective of occupational therapists: a worldwide validation study using the Delphi technique. Spinal Cord, 49,
46Spinal Cord Injury Educational Resources National Spinal Cord Injury Association (NSCIA):association that promotes independence, health and well being of individuals with spinal cord injury and disease through a free help-line, an on-line forum, nationwide chapters and support groups.Website:Paralyzed Veterans of America (PVA):offers numerous publications, fact sheets and authoritative clinical guidelines for SCI (in English and Spanish) and supports research by way of its Spinal Cord Research Foundation.Website:Spinal Cord Injury Information Network:Rich source of information on all topics related to SCI including medicine, liffestyle, religion, advocacy & technologyWebsite:Christopher and Dana Reeve Paralysis Resource Center (PRC):a program created to provide a comprehensive information source for people living with paralysis and their caregivers to promote health, community involvement and quality of life.Website:
47Spinal Cord Injury Educational Resources The University of Miami School of MedicineOffers an easy to use online manual on spinal cord injury health and wellnessWebsite:The University of Washington School of Medicine:Maintains a useful website with information on skin care, bowel and bladder management and other topics of concern for people with spinal cord injuriesWebsite:Craig Hospital:Located near Denver, specializes in the rehabiliation of SCI and TBI. Federally-supported educational materials are available online to help survivors maintain health and wellness. Emphasis on issues related to aging with a disabilityWebsite: (click on “spinal cord injury” then “health and wellness”
48Spinal Cord Injury Educational Resources North Carolina Office on Disability and Health:Promotes the health and wellness of people with disability in North Carolina through an integrated program of polocies, programs and researchWebsite:Shepherd Center:Key to Independence WorkbookWebsite:Take Control:A multi-media guide to SCIWebsite:North Carolina Spinal Cord Injury Association-