Case Study of a Person With a Spinal Cord Injury

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Case Study of a Person With a Spinal Cord Injury

• Julie Sinkosky, PT, DPT
• Magee Rehabilitation Hospital
• Philadelphia, PA

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• Question 1
• What is the primary cause of SCI in the United
  States?
• Sports
• Falls
• Motor Vehicle Crashes
• Violence

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Epidemiology of Traumatic Spinal Cord Injury in
the U.S.

• 11,000 patients/year in the U.S.
• Average age 37.6 years
• Sex 80 male
• Ethnicity African Americans and Hispanics
• Causes MVC 48, falls 23, violence 14, sports
  9, other 6
• Occur more often in the warmer months and on
  weekend days
• Percentage of Injuries by ASIA Classification
• Incomplete tetraplegia 34.5
• Complete paraplegia 23.1
• Complete tetraplegia 18.4
• Incomplete paraplegia 17.5

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Initial Evaluation July 31, 2010

• 23 y/o African American male s/p multiple GSW to
  abdomen, left elbow, buttocks and left flank on
  May 30, 2010

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• Surgeries
• Exploratory laproscopy and small bowel resection
  on 05/30/10
• Appendectomy
• Left radial artery repair with vein graft
• ORIF of left radius and ulna
• Left forearm fasciotomy and re-exploration of
  left arm
• Washout of left arm with closure of fasciotomy on
  06/02/10
• IVC filter placement on 06/03/10
• Xray revealed fracture of proximal phalanx of 3rd
  digit on right hand

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• No reported PMH or PSH
• Denies family history of HTN, DM, CVA, CAD/MI, CA
• Smokes 1 pack/day x10 years
• Denies any substance abuse
• TLSO brace at all times when OOB per medical chart

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• What other pertinent information do you want to
  obtain from this patient during your subjective
  interview?

Anticipated D/C plan Home set-up Family/caregiver
support Prior level of mobility DME
owned Occupation/social history Pain
levels Highlights of acute care hospital
stay Expectation for acute rehabilitation ? GOALS!
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• What objective information would you like to
  evaluate and why?

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Initial Evaluation

• ROM
• LE WNL B/L
• UE LUE elbow extension, wrist extension
  impairments secondary to scar adhesions, R hand
  3rd digit impairments in PIP flex/ext
• MMT
• LE no volitional movement noted 0/5 in major
  muscle groups
• UE formally tested by OT WFL for WC propulsion
  and transfers
• DTR
• Not tested

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Initial Evaluation

• Objective Information

Functional Task Level of Assistance
Rolling MAX A via logroll
Sit to Supine MAX A x2 for trunk/BLE assist on/off bed/mat
Supine to Sit MAX A x2 for trunk/BLE assist on/off bed/mat
Short sit scooting MAX A for lift with use of 4 push-up blocks
Transfers Dependent OHL, bed to/from MWC
MWC propulsion BUE propulsion 150 with supervision for safe obstacle negotiation
All within TLSO precautions
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American Spinal Injury Association (ASIA) Exam

• Sensory Exam
• 28 key dermatomes
• Test sharp/dull with pin and light touch with
  cotton tip applicator
• Face is the normal reference point
• 0, 1, 2 grades (absent, impaired, normal)
• Rectal exam for deep anal sensation present or
  absent.
• Motor Exam
• 10 key muscles (5 in UE, 5 in LE)
• Supine positioning for all of testing
• Graded 0-5 (no or -)
• External anal sphincter testing (not anal wink
  reflex)

Neurological Level of Injury most caudal level
at which both motor and sensory modalities are
intact on both sides of the body.
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ASIA Testing Results

• Sensory
• Intact sensation to sharp/dull and light touch
  C2-T10
• T11, T12, L1 inconsistent
• L2 and below no sensation
• No anal sensation
• Motor
• C5-T1 key muscles 5/5
• C5 elbow flexors, C6 wrist flexors, C7 elbow
  extensors, C8 long finger flexors, T1 small
  finger abductors
• L2-S1 0/5
• L2 hip flexors, L3 knee extensors, L4 ankle
  dorsiflexors, L5 long toe extensors, S1 ankle
  plantar flexors
• No voluntary anal contraction

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• Question 3

• True or False?
• This patient has an incomplete spinal cord injury.

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FALSE. Presents with absent sensory and motor
function at the lowest sacral segments
(S4-S5) Therefore, he is a complete injury, T10
ASIA A.
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• What type of outcome measures could you use to
  identify changes in function from initial eval to
  discharge?

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Outcome Measures for SCI

• Modified Barthel Index (MBI)
• measures the individual's performance on 10
  activities of daily living functions in the area
  of self-care, continence, and locomotion it
  measures the individual's performance of daily
  functions
• 10 items that are scored based on the amount of
  physical assistance required to perform the task
• The MBI is somewhat of a generic measure, having
  been used mostly for cerebrovascular diseases,
  such as stroke.
• Quadriplegia Index of Function (QIF)
• The QIF measures the level of independence in 10
  tasks of ADL categories (a) transfers, (b)
  grooming, (c) bathing, (d) feeding, (e) dressing,
  (f) wheelchair mobility, (g) bed activities, (h)
  bladder program, (i) bowel program, and (j)
  understanding of personal care.
• For the first 7 tasks, each item is scored
  separately 0 to 4 (independent, independent with
  devices, supervision, assistance needed,
  dependent). Last 3 tasks have specific scoring
• The total QIF score ranges from 0 to100.
• Most applicable to cervical level SCI for
  evaluating ADL reflecting hand function in
  nonambulatory tetraplegia.
• Spinal Cord Independence Measure (SCIM) I, II,
  III
• A scale developed specifically for people with
  SCI to evaluate their performance of ADL and to
  make functional assessments of this population
  sensitive to change.
• Composed of 19 items in 3 subscales (a)
  self-care (6 items, subscore 020), (b)
  respiration and sphincter management (4 items,
  subscore 040), and (c) mobility (9 items,
  subscore 040).
• The total score ranges from 0 to 100.
• Sensitive to change in function in persons with
  SCI

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• Magee uses the Functional Independence Measure
  (FIM)
• Model Spinal Cord Injury System Centers
• Required for Medicare reimbursement
• Performed within 72 hours of admission and D/C
• Multidisciplinary scoring
• Looks at caregiver burden of care
• taking worst score for each item within the 72
  hour window
• FIM Scores (for PT) at Initial Eval
• Bed/mat/chair transfer 1 (Dependent)
• Ambulation 0 (Activity does not occur)
• Stairs 0 (Activity does not occur)
• WC mobility 5 (Supervision)
• Distance modifier 3 (gt150)
• Primary means of mobility Wheelchair

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Interdiciplinary Team

• PT
• OT
• Nurse
• Physician/Medical Residents
• Nurse Practitioner
• Case Manager
• Psychologist
• Recreational Therapist

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Interventions/Treatment

• What are this patients impairments that are
  limiting his functional independence?

• LUE ROM
• LUE strength
• CV endurance/activity tolerance
• Tolerance to upright
• Absent volitional control of BLE
• Absent sensation below level of injury
• Impaired trunk balance
• TLSO precautions limiting trunk ROM

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• Question 2
• With a complete SCI at the T10 level, which of
  the following muscles would be innervated?
• Abdominal muscles above the umbilicus
• Quadriceps
• Psoas
• Illiacus

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• What interventions/treatment would you prioritize
  and why?

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Interventions/Treatment

• Bed mobility
• Transfers to bed/mat, level/unlevel
• Sit to/from supine
• Tilt table/standing frame
• Prone positioning
• Floor transfers
• Car transfer
• Weight shifting
• WC righting
• Wheelies
• WC breakdown/set-up
• PROM/self ROM
• UE strengthening
• Core strengthening/stabilization
• SCI education
• Balance- dynamic challenges in short/long sitting
• Direction of care for caregiver to perform
  dependent WC management on stairs, curb, ramp
• Stair bumping with Jay Protector

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Spinal Cord Injury Education

• If you dont tell them about it, they dont know!
• PTs as a part of the interdisciplinary team are
  critical in education to prevent complications.
• Must include
• Spinal Cord Anatomy/Physiology
• ASIA levels
• Bowel/bladder education
• Sexuality
• Pressure Sores
• Nutrition
• Complications of SCI (autonomic dysreflexia,
  heterotopic ossification, DVT, pulmonary
  complications, temperature imbalance, spasticity,
  contractures, osteoporosis, etc.)
• WC parts/breakdown/set-up, maintenance, repair

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• Question 3
• Which of the following is a medication commonly
  used to control spasticity?
• Neurontin
• Colace
• Baclofen
• Percocet

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• What are your expected functional outcomes at
  discharge for this patient?

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Expected functional outcomes(from M. Somers,
Spinal Cord Injury Functional Rehabilitation)

• T10-L1
• Bed skills Independent
• Transfers
• Level Independent
• Unlevel Independent
• Wheelchair skills Independent with manual WC
  indoor/outdoors on level and unlevel terrain
• Ambulation Assistance for functional
  (therapeutic?) ambulation using KAFOs and
  loftstrand crutches/RW

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Goal setting for inpatient rehabilitation stay

• Patients personal goal

I want to walk.
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Long Term Goals?

1. Patient will be independent with rolling to R and
   L in bed without TLSO to promote ability to
   reposition for pressure relief in bed.
2. Patient will be independent to perform sit
   to/from supine with BLE management in bed to come
   to short sitting prior to transfer into MWC.
3. Patient will be independent with level and
   unlevel squat pivot transfer, with BLE management
   throughout, bed to/from MWC to promote ability to
   transfer to various surfaces at home.
4. Patient will be modified independent with BUE MWC
   propulsion gt150 over level indoor/outdoor
   surfaces including up/down 3 grade, around
   obstacles and over doorway thresholds to allow pt
   ability to access various home and community
   environments safely.
5. Patient will be independent to verbally direct
   dependent MWC management up/down stairs, curb,
   and ramp with 100 accuracy to ensure safety with
   caregiver direction of care upon D/C.
6. Patient will be supervision for squat pivot
   transfer to/from passengers seat of car to
   promote safety with performance to family
   members cars.
7. Patient will demonstrate accuracy with recall of
   SCI education to promote knowledge of disability
   to decrease risk of SCI associated complications.

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During their stay

• Daily consult/interaction with rehab
  physician/resident and nurse practitioner as
  necessary
• Daily communication with nursing staff regarding
  overnight issues/changes to status
• Wound Care nurse/nutritionist/psychology consults
  as necessary during stay
• Weekly STG review to track progress toward LTG,
  modifications as necessary
• Re-evaluation weekly for utilization review for
  insurance approval
• Weekly meetings with interdisciplinary team to
  discuss any current issues, ELOS, and D/C
  planning
• Focus on function in inpatient rehab setting

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D/C plan

• ELOS at IE 6-8 weeks
• Admitted July 31, 2010 Discharge September 17,
  2010 (7 weeks)
• Attempted to complete family teaching, no family
  to teach, pt reported he planned to go home
  with a female friend
• Equipment needs
• Ordering of temporary highstrength lightweight
  MWC with cushion, backrest, and OT bathroom
  equipment
• Ordering of permanent ultralightweight MWC,
  cushion, and backrest
• Following order submission with letter of medical
  necessity, will take 3-6 months to be received

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FIM changes
IE D/C
Bed/mat/WC transfer 0 Dependent 7 Independent
Ambulation 0 Activity does not occur 1 Dependent
Stairs 0 Activity does not occur 1 Dependent via 2 person MWC carry
WC mobility 5 Supervision 6 Modified Independent
Primary means of mobility Wheelchair Wheelchair
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Functional Outcome
Functional Task Level of Assistance
Rolling Independent on bed/mat
Sit to Supine Independent on bed/mat for BLE management with use of BUE
Supine to Sit Independent on bed/mat for BLE management with use of BUE
Short sit scooting Independent on bed/mat
Transfers Independent for squat pivot transfer bed to/from MWC
MWC propulsion MOD I for BUE propulsion
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• Questions?

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References

• American Spinal Injury Association. (2008.)
  E-learning documents. Retrieved September 16,
  2010, from http//www.asia-spinalinjury.org/eLearn
  ing/.
• Anderson, K., et al. (2008) Functional recovery
  measures for spinal cord injury an
  evidence-based review for clinical practice and
  research. Journal of Spinal Cord Medicine, 31(2),
  133-44.
• Magee Rehabilitiation Hospital, Spinal Cord
  Injury Manual.
• Sisto, S.E., Druin, E., Silwinski, M.M. (2009).
  Spinal Cord Injuries Management and
  Rehabilitation. St. Louis Mosby Elsevier.
• Somers, M. (2001). Spinal Cord Injury Functional
  Rehabilitation. Upper Saddle River Prentice
  Hall, Inc.
• Spinal Cord Injury facts and figures at a
  glance. (2005.) Journal of Spinal Cord Medicine
  28 379-380.

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• Thank you!
• jsinkosky_at_mageerehab.org