Case Study of a Person With a Spinal Cord Injury

1. Case Study of a Person With a Spinal Cord Injury Julie Sinkosky, PT, DPT Magee Rehabilitation Hospital Philadelphia, PA

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

3. 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%

4. 23 y/o African American male s/p multiple GSW to abdomen, left elbow, buttocks and left flank on May 30, 2010 Initial Evaluation: July 31, 2010

5. 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

6. 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

7. 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!

8. What objective information would you like to evaluate and why?

9. 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

10. Initial Evaluation • Objective Information: * All within TLSO precautions

11. 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.

12. 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

13. Question #3 True or False? This patient has an incomplete spinal cord injury.

14. FALSE. Presents with absent sensory and motor function at the lowest sacral segments (S4-S5) Therefore, he is a complete injury, T10 ASIA A.

15. What type of outcome measures could you use to identify changes in function from initial eval to discharge?

16. 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 0–20), (b) respiration and sphincter management (4 items, subscore 0–40), and (c) mobility (9 items, subscore 0–40). • The total score ranges from 0 to 100. • Sensitive to change in function in persons with SCI

17. 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 (>150’) • Primary means of mobility = Wheelchair

18. Interdiciplinary Team • PT • OT • Nurse • Physician/Medical Residents • Nurse Practitioner • Case Manager • Psychologist • Recreational Therapist

19. Interventions/Treatment • What are this patient’s impairments that arelimiting 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

20. 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

21. What interventions/treatment would you prioritize and why?

22. 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

23. Spinal Cord Injury Education • If you don’t tell them about it, they don’t 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

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

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

26. 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

27. Involve the patient • Based on clinical experience • Consideration of comorbidities, precautions • PT knowledge of research • PT knowledge of functional outcomes for complete injuries at T10 level of mobility • Be realistic, but don’t take away hope Goal setting for inpatient rehabilitation stay Patient’s personal goal… “I want to walk.”

28. Long Term Goals? • Patient will be independent with rolling to R and L in bed without TLSO to promote ability to reposition for pressure relief in bed. • 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. • 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. • Patient will be modified independent with BUE MWC propulsion >150’ 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. • 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. • Patient will be supervision for squat pivot transfer to/from passenger’s seat of car to promote safety with performance to family members’ cars. • Patient will demonstrate accuracy with recall of SCI education to promote knowledge of disability to decrease risk of SCI associated complications.

29. 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

30. 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 D/C plan

31. FIM changes

32. Functional Outcome

33. Questions?

34. References • American Spinal Injury Association. (2008.) E-learning documents. Retrieved September 16, 2010, from http://www.asia-spinalinjury.org/eLearning/. • 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.

35. Thank you! jsinkosky@mageerehab.org