WK 9 Spinal Cord Injury

Considerations for Care Continuum​

*Acute Care*​ Include in d/c instructions or education session​ Focus on tools, resources​ *Inpatient Rehab/ARU*​ Practice, simulation​ Home visit​ *Home Health*​ Direct access to client's routine​ *Outpatient*​ Last opportunity to address​ Client can trial interventions, report back for feedback, adjust prn​

Acute Intervention

*Acute*:​ PROM, splinting, positioning, education​ *Splinting*:​ Acutely, can splint in wrist extension and thumb opposition​ Preserve web space, prevent deformity, promote functional position​ As pt begins to utilize UE for function, *Dorsal* will provide maximal sensory feedback when worn. ​

Frames of Reference

*Biomechanical​* Remedial/Restorative​ Increase muscle strength, improve or prevent ROM, increase endurance, enhance dexterity and manipulative skills, prevent loss of skin integrity​ Most often achieved through repetition and practice​ Motivate client despite occasional monotony of repetition​ *Rehabilitative​* Compensatory/Modify​ Teaching alternative methods for achieve performance (e.g. w/c > toilet transfer)​ Providing equipment that will assist pt to do tasks he/she can no longer do without assist (e.g. w/c for mobility)​

Sensation

*Body mapping* - explore the body to find out what is pleasant *hypersensitivity*- common with amputation desensitization - soft gentle material

Fatigue and Decreased Tolerance​

*Energy Conservation Education* ​ Pacing: Client can pause, or change to less strenuous activity​ Change positions, pace​ Most energy conservative position: Side-lying; supine​ *Planning ahead - scheduling​* Client should observe his or her routines related to energy-expending activities​ Time log/diary: carry over into other activities; observe trends​ Determine when energy is high, and low​ *Tantric Sex​* There is no defined beginning (foreplay), middle (penetration), or end (orgasm)​ Fosters communication, develops awareness of the other's needs​

T6-T12

*Helps FRONT TRUNK* innervation of all intercostal muscles and abdominal muscles allow for improved trunk control and endurance​ Limited ambulation with LE orthotics and assistive devices​

Dysphagia, Dysarthria, or Aphasia​

*Kissing​* Drooling, saliva management - tissues ​ *Oral Sex​* Oral motor control, aspiration, endurance​ *Aspiration*​ To minimize risk, client in higher position - natural chin tuck ​ Head elevated 30 degrees if in position for extended time​ *Communication*​ Non-verbal​ Hand signs and taps; particular sounds​ Clear signs for pain and discomfort​ Re-learn natural signs that indicate sex is desired (touching, kissing, stroking, eye to eye contact, nonverbal cues)​

Sexual Function of Males with SCI

*Psychogenic​* T11-L2 innervation​ Autonomic nerve pathways, in communication with cortex, leave cord, innervate genitalia​ Intact in most men with injuries below thoracic level​ ​ *Reflexogenic* - Arousal due to physical touch​ S2-S4 innervation​ Requires intact sacral cord​ Most often intact in men with injuries in cervical and high thoracic region​ ​ T12/L1 or Higher (UMN): ​ + Reflexogenic​ - Psychogenic​ ​ L2 - S1 (LMN)​ - Reflexogenic (however, some may retain)​ + Psychogenic​ ​ S2-S4​ - Reflexogenic​ + Psychogenic​

Complications After SCI

*Skin breakdown/pressure sores/DECUBITIS ulcers* Usually as a result of loss of sensory function Routine turning in bed, depression lifts, Huntleigh beds, specialized seating, cushions Pressure Relief: Every *30 minutes* when pt advances to upright sitting *Decreased vital capacity* Limited chest expansion and difficulty breathing with high level lesions Decreased ability to cough due to weakness in diaphragm and intercostal muscles Affects overall endurance *Poikilothermy* Body takes on temperatures of the environment as the body is unable to control blood vessel responses that conserve or dissipate heat Risk of becoming too hot or cold Interruption in pathways between periphery and hypothalamus *Osteoporosis* cause - no weight bearing Due to disuse of long bones Can result in pathological fractures

A COTA® is preparing a client with T1 spinal cord injury for discharge to home alone. What is the BEST recommendation for required home assistance?​ A. Homemaking assistance for a few hours a daily​ B. Attendant care 24 hours a day​ C. Attendant care 12 hours a day​ D. Homemaking assistance for several hours daily​

A

Deep vein thrombosis

A clot in the venous system that may produce infarction, usually originate in legs and can travel to lungs and cause a PE DVTs occur as a result of impaired vasomotor tone, loss of muscle tone, trauma to the vein wall, immobility, and hypercoagulation

Autonomic Dysreflexia

Autonomic Dysreflexia Occurs above T6 level Reflex of autonomic nervous system in response to noxious stimulus: distended bladder, fecal mass, pain stimuli Results in pounding headache, anxiety, perspiration, flushing, chills, hypertension, bradycardia First Action: Remove noxious stimulus immediately If BP is UP, elevate pt upright to lower cranial pressure

What piece of adaptive equipment is MOST useful for a client with an incomplete T2 spinal cord injury? ​ A. A weighted spoon​ B. A long-handled sponge​ C. A plate protector​ D. A button hook​

B

Bowel Program interventions

Bio-mechanical techniques : Transfer to toilet adaptive equipment modification or creation for the client education reaching techniques Use of sepository

Neurogenic Bladder​ Sacral

Bladder - controlled by sympathetic n. fibers T1-L3. ​ Relaxation of the bladder during filling​ Awareness of filling/distention - S2-S4​ Relaxation of sphincter to void​ UMNC1-T12 - SPASTIC bladder​ Lack awareness of distention, no voluntary voiding​ *Involuntary voiding reflexes* can cause incontinence and inability to fully empty​ Function: Can trigger reflex (suprapubic pressure), scheduled toileting, condom catheter, intermittent cath​ LMN L1/L2 and below- FLACCID bladder​ Lack awareness of distention, cannot void voluntarily OR involuntarily (*contractions absent*)​ Retention with overfill and urine leakage​ Function: Intermittent self - catheterization aka "in and out cath"​

S2-5

Bowel Bladder Genital - Sexual Function

A COTA® was asked to treat a client in the acute phase of spinal cord injury. What is most likely the COTA®'s INITIAL role during this phase?​ A. Evaluation of the client's ADL ability​ B. Evaluation of the client's strength​ C. Evaluation of total body positioning​ D. Evaluation of possible discharge location​

C

A COTA® is planning a feeding session with a client with a C5 spinal cord injury (SCI). Which feeding utensil or adaptive equipment would be MOST APPROPRIATE to introduce during the session?​ A. An electric self-feeder​ B. Utensils with built-up grips​ C. Mobile arm support​ D. Tenodesis orthosis​

C for people with weak upper extremity but have some ability for movement A- C1-4 D- C6 B- C7

Bracing for vertebral column

Cervical Collar Aspen Miami J Vista TLSO- thoracic lumbar sacral orthosis (picture)

Positioning

Due to individual needs, may need to alter body position​ Man-on-top; Woman-on-top, Side-lying​ Seated options​ Back supported with bolster, pillows/cushion​ In wheelchair ​ E.g. CVA - Can lie on affected side to unaffected arm is free to move​ Body pillows,

T1-T6

FULL upper extremity use innervation of top half of intercostal muscles to allow for more respiratory reserve, long muscles of back to allow for trunk control​ Standing with assistance, not practical for ADL​ Independent self catheterization​ Strong UE use​ *Helps BACK TRUNK*

C8

Flexor and extensor carpi ulnaris - *Complete wrist* extension, adduction, and abduction​ Flexor digitorum - *finger flexion*​ Flexor Pollicis - Thumb flexion, abduction, adduction, opposition​

Sexual Assessment Framework

Guide/Road Map for addressing the many components of SH​ Seven categories:​ 1. Sexual Knowledge​- values beliefs, anatomy and function 2. Sexual Behavior​- maintain social -sexual relationship 3. Sexual Self-view​- body image and self concept 4. Sexual Interest​- desire to engage in sex 5. Sexual Response​- amount of stim to reach the desired outcome ex: lubricant, penile rings, oral enhancement 6. Fertility and Contraception​- woman can still get pregnent, birthcontrol use and parenting. 7. Sexual Activity​- all motor function

Pressure Relief​

If pt has at least F+/3+ shoulder/elbow, can relieve pressure by leaning forward over feet. ​ Loops can be added to back frame of w/c​ Low quadriplegia (e.g. C7 with F+ or better TRICEPS), full depression weight shift likely​

S1-2

Knee Flex Plantar Flex

Sexual Activity Intervention

Maximize existing or remaining function of both mind and body ​ Adapt to limitations - environment, activity​ Planning ahead​ Establish, restore, remediate​ E.g. SCI, daily schedule that includes sexual activity while accounting for bowel and bladder routine, fatigue, Rx schedule/side effects​ Client factors: physical strength, endurance, prep activities Modify, compensate, adapt​ Revise environment or activity demands​ Collaborate with Assistive Tech and W/C Tech​ E.g. 92% of sexually active women with SCI - positioning during foreplay and intercourse​ Positioning cushions, adapted vibrators​ "Bedroom scene" - apply principles of ADL training toward the requirements of sexual interaction​

C5 AE

May (initially) requires (B) overhead suspension slings/MAS, wrist splints - long opponens​ Universal cuff; *Dorsal wrist extension support​* Scoop dish, plate guard, maybe angled utensils​ Communication: Adaptive devices for page turning, writing, button pushing​ Wanchik Writer; Eraser end of a pencil in a splint - to control buttons, push computer keys, etc​ Mobility: Power recline/tilt with arm control drive​ VS lightweight frame with hand rim modifications, e.g. push rim pegs; (may require some assist)​

Chronic Needs

May be followed on outpatient basis for several months to 2 years​ Vocational Training​ Periodically re-assess equipment needs​ Some pts elect to have a tendon transfer completed - improved grasp​ Will require training to learn to use the transferred muscles in new ways​ Susceptible to respiratory infections, UTI, Kidney Infections, skin breakdown, contracture development​

C1-3 worst injury

Neck extension, flexion, rotation, and lateral flexion Respirator dependent Dependent for ADL

Rehab/Active Phase​

OOB; develop upright tolerance​ Maintain and increase joint ROM​ Increase strength of all innervated muscles​ Increase physical endurance​ Maximize independence with ADL, IADL, work, leisure, etc​ Promote pressure relief training​ Assist with *psychosocial adjustment and self image*​ DME and home modifications​

Orthostatic Hypotension***

Occurs with patients with injuries at T6 and above Occurs when sympathetic outflow to blood vessels in extremities and abdomen is interrupted Decreased in cardiac output when patient is placed in an upright position Venous return to the heart is impaired and pooling of blood in feet occurs Blood pressure drops Signs: dizziness, pallor of face, excessive sweating above lesion level, blurred vision, syncope Can be prevented by helping patient assume an upright position in a gradual and slow manner Use of abdominal binders, compression garments, and medications When symptomatic, initial action should include: recline pt in bed or tip w/c back

Bowel Function​

Parasympathetic S2-4 - colon, rectum, anal sphincter​ Voluntary control of external sphincter​ Defecation involves reflex that increases peristalsis​ SCI ABOVE S2-4 = SPASTIC defecation reflex and LOSE voluntary control of the external sphincter​ Cannot control when a BM occurs​ Stool softener, suppository to trigger BM, or digital stimulation​ Scheduled toileting​ SCI AT S2-4 have FLACCID defecation reflex and lose anal sphincter tone​ Can't have a BM - fecal incontinence​ Digital stimulation, manual removal​

P-LI-SS-IT​

Permission Limited Information​ Specific Suggestions:​ Intensive Therapy - not in our scope of practice

Motor Limitations

ROM- increase mobility Arthritis - gentle stretch, hot bath

C5

Rhomboids - Scapular downward rotation Deltoids - Shoulder external rotation, flexion, extension Partial Rotator Cuff - Shoulder abduction and rotation Brachialis (partially), Brachioradialis - *Elbow flexion*, supination *Self feeding/light grooming* with adaptive equipment

C6

Rotator Cuff (RC) - *FULL shoulder rotation*, adduction, flexion, extension​ Serratus Anterior - Scapular adduction​ Clavicular Pectoralis - Horizontal shoulder adduction​ Total innervation of elbow flexors - *Strong elbow flexion* and supination​ Supinators - forearm supination​ Extensor carpi radialis - *Tenodesis action of hand* - radial wrist extension - can place items between palms​ *ADL*:​ Self feeding, light grooming with AE​ UB/LB Dress with AE​

Addressing Sexual Health​

SEX-PLISSIT​ Expression of concerns:​ Direct​ Indirect​ Not at all​ Sexual Assessment Framework​

ADLS

Sexual activity: "Engaging in activities that result in sexual satisfaction and/or meet relational or reproductive needs."​ Personal device care: "Using, cleaning, and maintaining personal care items such as hearing aids, contact lenses, glasses, orthotics, prosthetics, adaptive equipment, glucometers, and contraceptive and sexual devices." ​ Social Participation: Peer, friend: "Engaging in activities at different levels of interaction and intimacy, including engaging in desired sexual activity."​

C7 (- C8) AE

Should be able to hold utensils with built up handle or without any AE​ Depression lifts for pressure relief - C7 *Triceps!!​* *C8 - *Intrinsics* (partial)!​* < you want this with a splint Intrinsic plus is lumbrical grip Intrinsic minus is (picture)

Functional Considerations

Spine Precautions! BLT Until spine is stabilized, No MMT or strengthening of shoulder muscles until advised by physician Cervical and Thoracic May have brace! *Promote Tenodesis* - if applicable (C6) Allow wrist extensors and finger flexors to tighten to promote optimal tenodesis grasp power AKA do NOT extend wrist/fingers at same time; do not flex wrist/fingers at same time *Spinal Shock* Immediately after SCI, flaccid paralysis (days, weeks, months) As spasticity sets in, can use to assist in LB dressing

Spinal Shock

State of areflexia that occurs immediately after SCI and involves loss of all spinal reflexes below lesion level Patient experiences flaccid paralysis, loss of tendon reflexes, and loss of autonomic function Can last for hours, days, or weeks Upon resolution, spinal reflex activity returns

Initial Medical Management

Steroids may be given to reduce swelling *Spine stabilized* : Surgical - internal fixation Traction on bed frames Halo traction

Sexual Function of Females with SCI​

T11-L2 innervates uterus​ S2-4 innervates vulva and vagina​ Affects ability to lubricate​ Can use water soluble, non-lanolin base lubricant​ Menstruation​ Amenorrhea: May be absent for up to 1 year​ Still ovulating can still get pregnant​ Feminine napkins vs. tampons​

C6 (-C7): AE

Tenodesis! Via radial wrist extension​ "Wrist driven flexor hinge orthosis" or "Tenodesis splint" = using wrist extension to approximate thumb and forefinger in absence of finger flexion​ Adapted handles, button HOOK, *LOOPS on zippers*, pants​ Mobility: Manual is possible - lightweight with modified rims​ Communication: writing splint for keyboard use, button pushing, page turning​ Skin checks - self inspection with mirror with U cuff handle​ Weight shift - forward or side to side​

C4

Trapezius - Shoulder elevation, scapular adduction and depression Diaphragm - *Independent breathing, inspiration Max A for ADL*

QUIZ 3

Week 9 - SCI (~35 questions)​ Must know functional capabilities at all levels, especially Cervical levels​ Must know medical terminology​ Sexual Health will be only a handful of questions (~5)​

*Levels C1 - 4: Adaptive Equip*. Ways to remember : Myotome Dances​ Health Guardian. (2015, March 27). https://www.youtube.com/watch?v=qhxnYft9KKw​ Dominican OT. (2011, Feb 1). https://www.youtube.com/watch?v=zlLUv7Vh18k​

Will control environment via:​ Eyes​ Mouth​ Head​ Chin​ ex: w/c controls *ADL: Total (A)​* Focus: Caregiver training; Assisting the client in asserting himself to make needs known and instruct in all aspects of care​ Communication: Mouth Stick, high-tech computer access, ECU/EADL​ High Level 1-3: Talking is sometimes taxing or difficult​ C4: Mouth stick - page turning​ Picture : Tilt and space w/c - for pressure release every 30 min

Halo vest

allows early mobilization and stabilization 24/7

T12-L4:

hip flexion, hip abduction, knee extension​ Functional ambulation with BLE orthotics and assistive devices​ Wheelchair use for energy conservation​

L4-5

knee extension (weak), ankle dorsiflexion (weak)​ Functional ambulation with BLE orthotics​ Wheelchair for energy conservation​

C7​

​ Triceps - *Elbow Extension​* Pronator Teres - Forearm pronation​ Flexor Carpi radialis - Wrist flexion​ Flexor and Extensor digitorum - *very weak finger flexion and extension*​ *ADL*:​ (I) with feeding, grooming; dressing with AE​ Depression lifts​ Meal prep with AE​ Mobility with hand controls​