Occupational Therapy for Spinal Cord Injury II

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Occupational Therapy for Spinal Cord Injury (II)

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Incidence Prevalence

• Incidence
• 40 cases / million population
• Approx. 11,000 new cases each year
• Prevalence
• 721-906 / million population
• Between 250,000-400,000 persons

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Age at Injury

• SCI affects primarily young adults
• Average age at injury is 32.1 years
• since 1990, mean age is 35.3 years
• Trends
• increase in the mean age at injury

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Age at Injury
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• 81.5 are males
• 41 male to female ratio
• Trends
• slight decrease in the proportion of males
  injured through the years

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SPINAL CORD INJURIESCaused by sudden trauma
(USA).
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• ???? 32
• ???? 68
• ???? 93

• 1. Incomplete Tetraplegia 29.5
• 2. Complete Paraplegia 27.9
• 3. Incomplete Paraplegia 21.3
• 4. Complete Tetraplegia 18.5
• IT gt CP gt IP gt CT

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Life expectancy

• Life expectancy is the average remaining years of
  life for an individual.
• Life expectancies for persons with SCI continue
  to increase, but are still somewhat below life
  expectancies for those with no spinal cord
  injury. Mortality rates are significantly higher
  during the first year after injury than during
  subsequent years, particularly for severely
  injured persons.

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• ???? 43
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• Employed at time of injury
• 58 Employed
• 41 Unemployed
• 8 years post injury
• 34 employed para
• 24 employed - tetra
• In Tetraplegia employment improves with time
• 13.4 at 1 year, 38.5 at 25th anniversary
• Most employed have full-time jobs

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Assessment

• A. Occupational history
• B. Functional evaluation
• 1.Hand wrist functionactivity, grip strength
• 2.Vocational, ADL, access to home and community,
  leisure time activities, driving evaluation
• 3.ADL IADL
• 4.Leisure

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Assessment

• C. Physical evaluation
• 1. Muscle evaluation
• Passive range of motion
• Manual muscle test test all muscle/ key muscle
• 2. Sensory evaluation
• Dermatomes
• Light touch, pin prick, joint proprioception,
  stereognosis, kinesthesia

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Assessment

• 3. Muscle tone
• 4. Endurance
• Reevaluation
• perform on a monthly basis
• improving specific muscles should often tested on
  a weekly or daily basis (incomplete)

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Setting goals ordering priorities for meaningful
and relevant activities

• A. Functional expectations
• Incomplete cases
• Strengthen remaining muscles by repetitive
  resistive exercise to recruit motor units and
  then hypertrophy the muscle fibers
• Assistive Technology
• Complete cases
• NDT (Neurodevelopment Treatment)
• Orthoses
• Assistive Technology

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Setting goals

• B. Age-specific consideration
• 1. Adolescent and young adulthood
• Self-image, identity, independence
• 2. The older adult
• Downgrading of expected functional outcomes
• physical ( muscle strength, endurance, joint
  degeneration, bone decalcification, skin
  integrity, vision change)
• cognitive limitations

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Setting goals

• 3. Aging with spinal cord injury
• Long-term survival rate
• Unique problems
• Shoulder pain overuse of weak muscles, muscle
  imbalance
• Pressure ulcers
• Bone density?-- fracture
• Cardiovascular fitness
• Renal complications
• OTenergy conservation, joint protection,
  activity analysis

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Treatment

• Acute rehabilitation focus on support,
  education, and meaningful activities
• Educating patient and family peer/ group
  learning
• Encourage problem solving generation of
  information
• Focusing on discharge context home visit
• Balancing self-maintenance skills meaningful
  activities
• Choosing Assistive Technology Devices

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Assistive Technology Devices

• means any item, piece of equipment, or product
  system, whether acquired commercially, modified,
  or customized, that is used to increase,
  maintain, or improve functional capabilities of
  individuals with disabilities.

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Assistive Technology (AT)

• Low/high tech solutions that enable people with
  disabilities to
• function in a variety of environments
• Home, work, classroom, community
• engage in meaningful activities
• Performing ADLs, playing, learning, interacting
  socially, working, traveling, etc.
• Achieve independence

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Mobility Devices for SCI

• Manual wheelchair
• Power wheelchair
• Pushrim activated power assisted (PAPA)
  wheelchair
• Functional electrical stimulation (FES) walking
  devices
• Modified motorcycle

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Manual Wheelchair
Backrest
Armrest
Cushion
Hub/Rear Axle
Footrest
Pushrim/Handrim
Caster
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Power Wheelchair
iBOT mobility system
Pride  Jazzy 1143 Power Wheelchairs
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PAPA wheelchair
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FES Walking system
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Manual Wheelchair Setup

• Increases access to pushrim
• Reduces impact loading on the pushrims
• Reduces stroke frequency
• Enhances mobility
• Wheelies/curb climbing
• Decreases turning radius, downhill turning
  tendency, and castor flutter
• Effects stability
• Easy to fall
• Safety consideration

Boninger et al. 2001
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Vertical Axle Position

• Fingers should touch axle

• Elbow angle between 100 and 120

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Seat Width

• Too wide

• Just right

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Seat Backrest

• If subjects injury level is too high (eg. C4),
  high backrest is needed
• If subjects is a manual wheelchair user, lower
  the backrest height to just below the thoracic
  curve, and make sure the bottom of the backrest
  contacts the lumbar region.
• Why?? Easier to propel
• For newly injured patients trying out their first
  wheelchair, a litter high backrest is a good
  start

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The Choice Backrest Selection

• Should not interfere with motion of the arm

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AT devices for ADL
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AT devices for ADL
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Transfer
A
E
B
C
D
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Special treatment considerations based on level
of injury

• Individual with high tetraplegia C1 to C4
• C1C3 exteranl breathing device
• C4 assistance with ventilation (acute stage)
• Complication respiratory infection and pressure
  sore
• Role
• Select special equipment for life support
• Adapted device mouth stick

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Individuals with lower cervical injuries C5C8

• C5 individuals
• Deltoid and biceps are weak initially
• Shoulder-elbow support mobile arm support
• Driving W/C, feeding, hygiene grooming,
  tabletop activity (writing, cooking)
• Deltoid and biceps at 3/5 or greater/ good
  endurance not need MAS
• Grasp hold object splint or orthosis( Ratchet
  wrist-hand)/ universal cuff/ U- or C-shaped
  clamps (telephone or shaver)
• Dependent dressing bathing lack trunk
  control, falling risk

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Individual with lower cervical injuries C5C8

• C6
• Attain significantly higher levels of
  independence than C5 Individual
• Radial wrist extensor tenodesis grasp
• Pick up, hold, manipulate light object
• Stronger pinch use flexor hinge splint,
  tenodesis splint, wrist-driven WHO
• Rolling cross midline more forcefully

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Individual with lower cervical injuries C5C8

• C7
• Triceps
• Reach for objects above head level/ transfer with
  greater ease/ push a manual W/C
• C8
• Hand function extrinsic finger muscle, thumb
  flexors
• Limited hand dexterity strength absence of
  intrinsic finger thumb muscle
• Grasp pattern claw hand or intrinsic minus

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Surgical options for U/E

• Purpose restore hand function (pinch and grasp)
• C5, C6, C7 SCI Individual
• Surgery tendon transfer
• Proximal functional m.(4/5 or?) attach to distal
  paralyzed m. tendon
• Electrical stimulation system C5C6 Individual

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Table Expected achievement of SCI individuals
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END of OT for SCI
Questions?