1. Spinal Cord Injury
Dr. Hassan Sarsak, PhD, OT

2. What is Spinal cord injury ?
- Spinal cord injury causes a disruption in the motor and sensory pathways at the site of the lesion . - Since the nerve roots are segmental , a thorough evaluation of motor and sensory function can identify the level of lesion .

3. Spinal shock:
Immediately after the injury , a period of spinal shock occurs, characterized by Areflexia at the below of the level of injury.
Spinal shock may last hours, days, weeks.
- As soon as spinal shock subsides, reflexes below the level of injury return and become hyperactive.
Areflexia: flaccid
Subside: become less intense, go away

4. Prevalence & Incidence:
- The numbers of people with SCI alive today in the United States is estimated to be in range 0f 225,000 to 288,000.
- Spinal cord injury is relatively rare, afflicting approximately 11,000 people in a year in United states.
- Most occur in Males 4:1 Female persist over the past decades.
-  The average age of injury occurred between ages between years. 

5. Causes and Risk Factors:
1) Motor vehicle accidents. 2) Falls. 3) Acts of violence. 4) Sports injury. 5) Others unknown.

6. 1) Quadriplegia (Tetraplegia):
Levels of Injury:
results in functional impairment in the arms , trunk , legs, and pelvic organs. Quadriplegia is defined as an impairment in motor and / or sensory function in cervical segments of the spinal cord.
1) Quadriplegia (Tetraplegia):
refers to motor and sensory impairment at the thoracic , lumbar , or sacral segments of the cord. Paraplegia results in sparing of functionn and , depending on the level of the lesion , impairment of the trunk , legs , and pelvic organs.
2) Paraplegia:
Higher level vs. lower level SCIs

7. Functional level: a term level used by occupational and physical therapist , refers to the lowest segment at which strength of key muscles is graded 3+ or above out of 5 on MMT and sensation is intact .
Two other terms commonly used with people with spinal cord injuries :
1 ) Complete injury: consists of absence of sensory or motor function in the lowest sacral segments .
2) Incomplete injury: should be used only when there is partial preservation of sensory and / or motor function below the sacral segments.

8. ASIA impairment scale
A = Complete: No sensory or motor function is preserved in the sacral segments S4-S5
B = Incomplete: sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5
C = Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade < 3
D = Incomplete: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade ≥ 3
E = Normal: motor and sensory function are normal
American Spinal Injury Association (ASIA) muscle list is used for examination

9. Specific cord lesions Central Cord syndrome
Incomplete injury most common to the cervical region in which the center part of the cord is damaged. The lesion results in greater weakness in the upper limbs than in the lower limbs, with sacral sparing
Common in older adults

10. Specific cord lesions Brown-Sequard syndrome
Half of the cord is damaged, causing ipsilateral proprioceptive and motor loss and contralateral loss of pain and temperature sensation

11. Specific cord lesions Anterior Cord Syndrome
Loss with variable motor and sensory loss and preservation of proprioception

12. Specific cord lesions Conus Medullaris Syndrome
Lesions to the sacral cord and lumbar nerve roots within the spinal canal, commonly results in areflexic bladder, bowels and lower limbs
Hyperreflexic (spastic) bladder tends to hold less urine than before SCI. You may have frequent small urinations or not be able to empty at all. The bladder may not empty with each contraction. This type of bladder is common with SCI above the sacral level.
Areflexic (flaccid) bladder has lost its ability to contract, allowing large amounts of urine to accumulate. The bladder can overfill and leak. The urine “spills over” like a glass that’s too full of water. This type of bladder activity is common when SCI affects the spinal nerves in your sacral spinal cord

13. Specific cord lesions Cauda Equina Syndrome
Lower motor neuron injury to the lumbosacral nerve roots within the spinal canal, results in areflexic bladder, bowel, and lower limbs

14. Impairments and OT Role with
Rispiration
Autonomic Dysreflexia
Hypotension
Pressure Ulcers
bowel and bladder
Sexual function
Temperature regulation
Fatigue
Pain
Spasticity and spasms
Deep vien thrombosis
Heterotopic ossification
Thrombosis: blood clotting

15. Rispiration
Many patients with SCI have compromised breathing especially for individual with cervical injuries .
respiratory complication specifically pneumonia have been identified as the leading cause of death in the first year of life after SCI.
in lesions above C4 ,damage to the phrenic nerve results in partial or complete paralysis of the diaphragm.
These patients require ventilator support .
Pneumonia: lung inflammation
Phrenic nerve (C3-C5)

16. Rispiration
lower cervical and thoracic injuries can result in paralysis of other breathing muscles such as the intercostals ,abdominals or latissimus dorsi. patient with such injuries also have impaired respiration.
OT Role
The care team works to achieve adequate bronchial hygiene and to facilitate good breathing at rest and during activities .
To facilitate breathing: we want to open the chest and airways through facilitating chest, trunk, head and neck, and UE extension as well as shoulders abduction, external rotation, and elevation. If the pt is static, we use power seat functions that have the same effect (tilt in space, recline, elevating legrests, standing, and seat elevator)

17. Autonomic Dysreflexia
Autonomic dysrflexia, a sudden dangerous increase in blood pressure is possibly life- threatening complication associated with lesion at the T6 level or above .
Proper treatment of autonomic dysreflexia involves administration of anti-hypertensives along with immediate determination and removal of the triggering stimuli. Often, sitting the patient up and dangling legs over the bedside can reduce blood pressures below dangerous levels and provide partial symptom relief. Tight clothing and stockings should be removed. Straight catheterization of the bladder every 4 to 6 hrs, or relief of a blocked urinary catheter tube may resolve the problem. The rectum should be cleared of stool impaction, using anaesthetic lubricating jelly. If the noxious precipitating trigger cannot be identified, drug treatment is needed to decrease elevating intracranial pressure until further studies can identify the cause.
Drug treatment includes the rapidly acting vasodilators,

18. Hypotension Orthostatic hypotension or postural hypotension:
-Orthostatic hypotension is a sudden drop in blood pressure occurring when a person assumes an upright position.
-Most common in patient with lesions at the T6 level and above it is caused by impaired autonomic regulation. A decrease occurs in the returning blood supply to the heart.
-Orthostatic hypotension is a aggravated by a prolonged stay in bed. When the patient attempts to sit up, the blood rushes down to the leg. the patient may complain of light headiness or dizziness and may faint on moving from reclined to upright .

19. Hypotension Role of OT :
The therapist must use caution when sitting the patient up by having the patient move slowly and in stages and letting the blood pressure adjust to the change.
Elevating the bed, using a tilt table, or using a reclining wheelchair can accomplish this.

20. Pressure Ulcers
PUs are common problem for people with SCI. the constant pressure caused by maintaining a static position without shifting weight can lead to skin breakdown.
most pressure relief efforts are aimed at the buttocks .,many other parts of the body
are vulnerable in patient with higher lesions
for high tetraplegic patients, these areas may also include the spine of the scapula and the back of the head.

21. Pressure Ulcers
OT Role: all insensate (no sensation) areas must be inspected daily. bed-bound patients must change their position every two hours wheelchair-bound must relief pressure on their buttocks every hour

22. Sexual function
The need for emotional and physical intimacy does not diminish after SCI. Usually some patient with complete injuries are unable to have psychogenic erection and ejaculation. Patients with complete injuries at S2-5 lose bowel, bladder and genital reflexes and have complete loss of erection. As with physical performance, male fertility is decreased after SCI. Although sexual and reproductive functioning is less affected in women, sex, fertility , and menopause are still issues of concern. Some consequences related to these issues are dysreflexia and bladder incontinence during intercourse and complications of pregnancy and delivery .
Menopause: the ceasing of menstruation

23. Sexual function Role of OT :
The OT addresses many issues that related to sexuality
some examples for the therapist's involvement :
1. may be helping patients to groom themselves to improve their appearance
2. Creating a cozy environment that allows for intimacy
3. Finding equipment to compensate for lack of hand function

24. bowel and bladder
Bowel and bladder function is controlled in the S2-5 SPINAL SEGEMENTS . Therefore , all persons with complete lesions at and above the S2-5 levels lose their ability to void and defecate voluntary.
Incomplete injuries and disruption at the S2-5 levels, many present with a mixed sensory and/ or motor picture. For example, a person may feel the urge but may lack the ability to void and defecate voluntarily.
Void: emptying
Defecate: feces secretion

25. bowel and bladder
The goal of bowel and bladder program is to allow the person to develop an elimination routine that supports health, reduces potential complication, and allows the freedom to engage in life roles without disruption.

26. Role of OT :
Common bladder practices include use of either intermittent catheterization or reflex voiding.
Reflex voiding: bladder emptying through contractions

27. Temperature regulation
Many people with SCI cannot regulate body temperature , which can lead to hypothermia or heat stroke.
Due to decreased sensation, patients may become severely sunburned or frostbitten.
Education in the importance of neutral temperature and the prevention of skin exposure to sun and severe temperature is an important part of OT program.

28. Pain
Acute and chronic pain is common after SCI, approximately 65% of individuals with SCI report having chronic pain.
types of pain:
1) Most common pain in people with SCI is mechanical pain: local soft tissue pain common in the shoulder of person with tetraplegia
2) Radicular pain: segmental root pain which follows the segmental distribution of the nerve
3) Neuropathic pain: central pain that originates on spinal cord and is thought to be the result of misdirected neural sprouting after the injury

29. Pain
People with SCI pain demonstrate activity limitation, lack of participation and depression. OT Role: 1) Thorough evaluation, pain management??? 2) Because most persons continue to live with some pain through their lives and new pain arises with aging our main contribution is in changing habits and roles and facilitating engagement in meaningful activities and full participation.
Pain management; desensitization???

30. Fatigue Factors that contribute to fatigue:
Physiological , psychological and environmental factor (restriction)
2) Physical factor: Persistent pain, antispasmodic medication and prolonged bed rest
3) Restless night interrupted by hospital routine
 OT Role:
Observe and listen to the patient, find optimal waking hours for activities, and report nighttime sleep disturbances

31. Spasticity and spasms
SCI result in an increase in transmission within the synaptic starch reflex which result in spasticity
Colonic (alternate involuntary contraction) or tonic (continuous involuntary contraction) spasm develops triggered by sensory stimuli
Sever spasticity may hinder function
Hypertoncity of hip and knee adductor can make donning pants difficult
Spasticity can lead to contracture
Spasticity is defined as an involuntary, velocity-dependent, increased resistance to stretch
A muscle contracture is a permanent shortening of a muscle or joint. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area

32. Spasticity and spasms OT Role:
Routine positioning in bed and in wheelchair (schedule).
power seat functions? Ideal?
2) Range of motion exercise.

33. Deep vien thrombosis
Formation of blood clot, the clot may develop forming an embolus that may travel and occlude pulmonary circulation.
OT Role:
Prevent this condition by observing any asymmetry in the lower extremities in color, size and temperature when DVT is identified patient must has complete bed rest and anticoagulant to prevent embolus.
Patient and family education.

34. Heterotopic ossification
Pathological bone formation in joints has been recorded in % of SCI patient , appear 1-4 month after injury
Most often seen in hip and shoulder joints and can result in joint contracture
OT Role:
First indication of heterotopic ossification is range of motion limitation

35. Heterotopic ossification
OT Role Cont.:
OT must use each range of motion sensation to monitor joint range especially in patient with spastic muscle.
Positioning in bed and wheelchair.

36. Psychosocial Adaptation.

37. Psychosocial Adaptation
SCI may include periods of shock, anxiety, denial, depression , internalized and externalized anger, adjustment , acknowledgment .

39. depression:
Many pt. have varying degree of depression, sadness , or grief.
After SCI up to 25% of men and 47% women have symptoms of depression (lack of social, occupational, participate less in worker, volunteer , student role )
Level of injury dose not appear to be associated with depressive.
SCI is an emotionally traumatic and overwhelming event.
Emotional reaction and the influence of these emotions on the pt and therapeutic process.

40. Psychosocial Adaptation
OT Role:
- Provide psychological support when pt sadness
- Select activity with just right challenge
when providing information don't too much details.
- (find opportunity for a teachable moment for particular chunk of information and be sensitive of pt signs to help you determine how to proceed and when to stop) .
- Accept pt. emotional states without judging them.

41. Psychosocial Adaptation
OT Role Cont.:
- Create opportunities for peer education and support, individuals with similar levels of injury can truly understand the pain that comes with SCI and may help the therapeutic process.

42. Assessments and Goals

43. Assessments
Assessment in occupational therapy after SCI include all level of occupational functioning.

44. Occupational Profile
- To gather deeper understanding of pt role, activities, and the meaning behind the
activities , use open- ended questions.
- Charting typical day's schedule prior to injury allows for creative questionnaire and enables the therapist to sketch a person's habits, routines, and other activities.

45. Occupational Profile
The Canadian occupational performance measure (COPM) best test .
is a measure of a client's self-perception of occupational performance in the areas of self-care, productivity and leisure.
The COPM is administered using a semi-structured interview
- It focuses on finding out pt occupational goals and their priorities

46. Evaluation
1) Evaluation of performance skills: - Spinal stability must be established prior to any physical contact with pt.
- The physical assessments include upper extremity , ROM , strength, muscle tone, sensation, endurance, trunk balance ,fatigability, pain.

47. Evaluation
Hand and wrist of the pt with tetraplegia:
-evaluation; physical and functional.
Old:
-Sollerman hand function test.
A 20 item objective measure designed to assess hand function with 7 different hand grips of persons with hand dysfunction.
-Jebsen test of hand function.
The Jebsen Test of Hand Function is used to assess a broad range of hand functions required for activities of daily living.
The time needed to complete a variety of subtests is measured, with high scores indicative of abnormality.

48. New:
-Vadenberge hand and arm function test
-Tetrablegia hand activity questionnaire
-Pinch and grip strength test by dynamometer when hand muscles are functioning

49. Evaluation 2) Evaluation of performance in area of occupation:
(ADL , IADL)
Functional independence measure ( FIM) most use
Quadriplegia index of function
Assesses ADL's performed with the hands among non-ambulatory individuals with cervical SCI
Modified barthel index
the Barthel Index assesses functional independence
catz-itzkovich spinal cord independence measure ( this functional instrument measures self-care , respiration , sphincter management, & mobility)

50. Evaluation
2. leisure: COPM interest inventories; interest checklist, OT priority checklist, Role checklist

51. Evaluation
3. School and Vocation: a full vocational evaluation is rarely performed during acute rehabilitation because pt are focused on more immediate challenges. Many have lost the physical ability to engage in prior occupation. Vocational exploration begins with defining pt ability and interest . Observation of factors such as hand function and work habits contribute information for the prevocational team and department of vocational rehabilitation.

52. Evaluation 4. home and community:
The home visit is an invaluable assessment tool for the person with SCI and the earlier it is performed the better.
This visit allows the therapist to assess home accessibility and safety and to evaluate the capacity of pt and their family to problem solve.
Assessing transportation issues is important as persons with SCI must often find new ways to get around .
This evaluation may involve taking a bus for first time or referring the pt to special disabled driving services.

53. Setting Goals
Answers to the following questions help pt. and therapist set priorities, establish short term goals and start treatment while evaluation is still in progress:
What must be done to prevent further deformities and complication?
What activity is important to the pt. to engage in right now?
The development of short term goal stems from the therapist ability to perform an activity analysis.
Short term goals address many functional performance areas and tasks underling problem or the component skills necessary to perform an ADL.

54. Setting Goals
For example a person with C4 tetraplegia who wants to use a mouth stick for word processing on the computer must first tolerate sitting upright in the wheelchair for significant period.
Increasing tolerance for sitting upright is an appropriate short term goal for achieving the independence of mouth stick computer use.

55. Setting Goals Age specific considerations:
1) Adolescence and young adulthood adolescence with SCI must deal with complicating normal development factor coupled with new impairment and disabilities .
psychological adaptation to the injury may be especially difficult for adolescence as the injury comes in the midst of development of adult self-image, identity, & independence .

56. Setting Goals
-Reentering the student role (meeting with school personnel and visiting the school with pt.)
-Sexual role _ must be assured that individuals with SCI can remain sexually active.
-Driver role _ driving if possible may provide the adolescent with valuable sense of empowerment, independence, & increased motivation.
-The parents must be supportive and must be part of the team, helping the pt make appropriate choices. parents must also participate in educational sessions to ensure consistency in treatment.

57. Setting Goals
2) The older adult: Most geriatric SCI are attributed to falls that result in lesions at the cervical level The central cord syndrome is common among the elderly SCI population. Important factors are decrease in muscle strength , endurance, energy, physical fitness , joint degeneration, bone decalcification , skin integrity, cognitive, vision , emotional change, and require more assistance in ADL, etc.

58. Setting Goals Aging with SCI:
Using the upper limbs for mobility, overuse of weak muscle, and muscle imbalance may cause chronic shoulder pain and less often elbow and wrist pain .
Body changes skin, pressure ulcer, decrease bone density, fracture, impaired cardiovascular fitness , renal and bowel complication, depression, increase in functional dependence , decrease mobility.
OT using energy conservation, joint protection, activity analysis , educate pt in restructuring activities to accommodate the new condition.
An aging pt once independent in all self-maintenance skill may need help in the morning to conserve energy for work.

59. Intervention

60. Acute recovery focus on support and prevention
Immediately after injury patient is immobilized in traction ( pulling force to treat muscle and skeletal disorder) and waiting to hear whether surgery is required to stabilize the supine and to prevent pressure ulcer patient is put in a rotating bed, in the ICU medical and surgical procedures take precedence over therapy
Therapist must be flexible often seeing the patient for brief period one or two 15 minutes session per day may be helpful ,OT initial contact should be within 24 hours of admission.

61. Goal of therapy in the acute recovery phase:
1) Ongoing patient and family support.
2) Provide some environmental controls to help the patient get some control.
3) Maintain normal upper limb joint ROM and prevent deformities.

62. To prevent ROM limitation therapist use positioning technique and ROM exercise as well as to consider the comfort of patient and allow a good night sleep, ROM exercise must be augmented with proper positioning in the bed and wheelchair
Person with tetraplegia tend to lie with their arm adducted close to their body internally rotated and with elbow flexed
Scapular rotation, shoulder scaption (functional movement between flexion and abduction ), shoulder external rotation, elbow abduction and forearm pronation exercises
movement in these joint which
susceptible to contracture must be
monitored

63. Hands are fitted in resting hand splint
Upper limbs are placed in some abduction or external rotation.
Range of motion to the hand of the tetraplegic patient is performed in a special way to facilitate tenodesis grasp.
passive opening to fingers when the wrist is flexed and closing the finger when the wrist is extended.
Tenodesis grasp helps in mastering different grasp patterns such as spherical, cylindrical, hook, etc.

64. 1) Educating patient and family
Acute rehabilitation focus on support, education and meaningful activities
1) Educating patient and family
OT role:
continue to provide education and support and helping them to explore meaningful activities those restore a sense of efficacy and self esteem 
Group learning is widely used to inform and invite group dialogue on different topics

65. 2) Self-efficacy and self-management skills
The therapist must encourage patient in taking an active role in managing their care, in evaluating behavior and self-reflecting about failure and success, we also educate our patients to be problem solver which encourage active participation
Engaging the patient in visualizing post discharged activities at home helps make treatment relevant .
3) Focusing on the discharge context: objects , locations and people central to the patient.

66. 4) Balancing self-maintenance skills and meaningful activity.
Most patient are relearning skills that they mastered in childhood, for many patients this training is frustrating the therapist has the difficult task of helping the patients see when relearning skills is valuable and when the skill should be accomplished .
Goal is the attainment of optimal DESIRED functional independence not the attainment of maximal functional independence .
Functional expectation chart helps us understand the range of expectations for a given level of injury considering only the motor and sensory status of the patient.

67. 5) Choosing equipment:
Most person with SCI require lifetime use of wheelchair for their mobility, choosing optimal wheelchair requires great expertise and has important implication for ease of mobility, accessibility and participation.
Example : if a young adult with a functional level of c6 is returning to collage following a rehabilitation stay and would like to use an attractive looking wheelchair to look and feel less disabled, questions about the layout of campus, the terrain and distances between classes must be answered prior the recommendation of optimal wheelchair .
The persons endurance, posture and transportation are factors that must all be considered in selecting either manual wheelchair or a power wheelchair.

68. Special treatment consideration based on level of injury.
1) tetraplegia
2) paraplegia
C3, C4: electric feeder, chin switch
C5: dorsal splint with universal cuff (used when client has no functional grasp), mobile arm support
C6: tenodesis splint, rocker knife, dycem cup with large handles
C5, C6: we want to improve tenodesis grasp
C8: joystick control

69. Patient with high tetraplegia: c1- c4
Patient with complete C1 -C3 requires an external breathing device because their diaphragm is either paralyzed or only partially innervated
Persons with c4 tetraplegia require assistance in ventilation during acute care but as the diaphragm strengthen they are able to breathe independently
People with complete high tetraplegia are paralyzed from the neck down these patients require a highly specialized team to stabilize them medically and prevent complications

70. Patient with high tetraplegia: c1- c4
OT role:
When working with this population must be comfortable with nursing procedures. These tasks include suctioning, manually ventilating the patient and proficiently managing the ventilator.
Providing the family and patient with care while preparing them for discharge.
Teaching them to direct their own care.
Helping them select specialized and sophisticated equipment for life support , mobility and ADL.
Helping them to the use of mouth sticks which are rigid long roods that held in the patient mouth that allow the patient to perform activities such as turning pages and typing.

71. Patient with lower cervical injury (c5 – c8)
Similar to acute recovery stage intervention.
(Positioning, splinting and range of motion)
Strengthening is an important goal in this phase can be performed by using weights; pulley system, skateboards, suspension slings and modalities such as biofeedback and neuromuscular electrical stimulation.

72. C5 tetraplegia
Deltoid and biceps key muscles for this level of injury are weak so upper limb requires support to function.
OT Role:
1) Mobile arm support (ball bearing feeder) is a mechanical device attached to the wheelchair. This shoulder and elbow support carries the weight of the arm and reduces friction, this mobile arm can assist in driving wheelchair, feeding and hygiene
when the strength of the deltoid and biceps is 3+/ 5 and endurance is good patient can engage in activities without arm mobile.

73. C5 tetraplegia
2) patient need away to hold and grasp object since their wrist and hand are paralyzed , the wrist must be stabilize with a splint orthosis and the device attached to the hand to enable the person to perform the activities (universal cuff )
patients can master tabletop activities.
They lack trunk control and muscles below the shoulder, so they are mostly dependent in dressing and bathing with adequate emotional and financial resources can engage in a meaningful productive activity.

74. C6 – c7 tetraplegia Higher level of independence than C5 patient
The addition of radial wrist extensors allows patient to close their fingers with a tenodesis grasp (critical functional enhancement ), the wrist driven wrist hand orothosis or the flexor hinge splint and tenodesis splint is the metal device that transfer power from the extended wrist to radial fingers allowing stronger pinch .

75.   C6 – c7 tetraplegia
More fully innervated proximal scapular and shoulder muscles rotator cuff, deltoid and biceps allow for an increase in upper limb strength and endurance patient can also roll in a bed and their arm can cross the midline more forcefully with the addition of clavicular pectoralis muscle.
The ability to use triceps, the key muscle for tetraplegia allows patient to reach for object above head level such as items in store shelf, transfer with ease, and push manual wheelchair .

76. C8 tetraplegia
Hand dexterity and strength is limited by the absence of intrinsic finger and thumb muscles
Hand function is significantly improved with addition of extrinsic finger muscles and thumb flexors
Person with complete c8 tetraplegia grasp objects with MCPS joint in extension and PIP and DIP in flexion (claw hand)

77. Surgical options for the upper extremities.
The top priority of many individuals with SCI is to restore hand function
to improve hand function persons with SCI may have surgical options these options do not restore a normal hand but aim to restore pinch, grasp and reach
Tendon transfer surgeries are recommended only after full spontaneous motor and sensory recovery no earlier than a year after injury  
Upper limb reconstructive surgery for increasing motion and function of upper extremities

78. Surgical options for the upper extremities.
Role of OT:
Preoperative and postoperative evaluation, education, wound care, motor function, and consistent communication with the operating physician

79. The patient with paraplegia
People with complete and incomplete paraplegia are independent in self- maintenance , self enhancement and self-advancement roles but they require assistance with heavy housekeeping 
Paraplegics with injuries at T10 and below may attain skill more readily than patients with higher injuries
Good trunk control enables a person with low paraplegia to bend down and from side to side without fear of falling forward

80. The patient with paraplegia
Skills performed while up-right (bowel management , bathing and lower body dressing) require the patient with higher injury to secure the trunk by supporting body by one arm while performing the activity with the other to prevent falls
OT role:
shift to self -enhancement and self- advancement roles

81. The ambulatory patient: incomplete paraplegia and tetraplegia
Although many individuals with SCI are able to walk but majority of them wheelchair users
OT must clearly understand ambulation goals (ambulation aids , braces ) soon after admission.  
Ambulatory patients with tetraplegia pose the greatest challenge with their often weak upper extremities.

82. The ambulatory patient: incomplete paraplegia
and tetraplegia.
In wheelchair, equipment such as lapboards , armrests, and mobile arm supports support weak arms and allow for function. When upper limb proximal muscles are weak , hand function becomes difficult or impossible , since the patient lacks mechanism for bringing the hand to the mouth or face.

83. Concomitant Brain Injury and Cognitive Defects :
Much attention is given to the visible paralysis of the injured patient, while less visible traumatic brain injury may be overlooked .
Diffuse or focal and mild or severe head injuries are common. The percentage of patients who suffer concomitant injuries to the brain and spinal cord may be as high as 40 – 50 % .
Concomitant: associated with

84. OT role:
OT must be vigilant for clues of brain injury in the first encounters with the patient. A period of unconsciousness and post – traumatic amnesia raises a red flag. Therapist should ask patients directly whether they have trouble remembering events or sense any changes in their thinking
The family is excellent source of information as they know pre – morbid cognitive status of the patient.
The evaluation of the patient is made more challenging with factors such as fatigue, medication side effects, pain, depression, sleep deprivation and sensory deprivation.

85. Transition: Restoring Roles at Home and in the Community
A quicker more effective transition is essential as acute rehabilitation length of continue to decrease .
OT role
impairment reduction and increased physical independence
must engage in moving the person toward a life of managing disability, maintaining general health, preventing complications, and managing social , occupational and financial environment that are often difficult and complex.
transition from a protective role to a “ launching “ role exposing the person to the real world and promoting autonomy key elements.

86. Transition: Restoring Roles at Home and in the Community
The therapist must document the need for longer hospitalization.
Orthotic training often begins during the last days of hospitalization and continues during outpatient visits to ensure good fit and use.
Outpatient OT should begin and or continue working on goals and skills that move the patient toward greater community integration. Therapist minimizes barriers to receiving therapy after discharge. A frequent barrier is lack of transportation.
Clients and their families are encouraged to seek health care.
ATD / DME DELIVERY

87. Adaptation: Focus on Facilitation Toward Full Participation
The unemployment rate of individuals with SCI is significantly higher than in the general population , and income is lower.
Some studies show that people with SCI patients have so much free time.

88.   Roles of OT:
1) Therapist must encourage persons with SCI to develop competencies and satisfaction in life roles.
2) Help individuals with SCI analyze their daily life, find solution to simplify daily routines, and engage in creative problem solving.

89. THANK YOU 