Occupational Therapy/OT in Spinal Cord Injury

OT in spinal cord injury rehabilitation OTprinciple
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SCI occurs when three is damage to the spinal cord due to trauma, disease process, and inadequate blood supply to the spinal cord or congenital neural tube defect. In this article, we will discuss SCI rehabilitation and, and what are the treatments/interventions option available for OT in spinal cord injury?

To know more about spinal cord injury: causes, classification, complication, prevention, and treatment options available click here.

The goal of all phases of rehabilitation is to help individuals with SCI to reach his/her full potential after injury and achieve the maximum level of independence.

Rehabilitation programs for spinal cord injury patients may differ from individual to individual because of their uniqueness and severity of the injury. Now we will discuss about short evaluation and then OT in Spinal cord injury rehabilitation.

Occupational Therapy Evaluation

Evaluation is an ongoing process that requires the occupational therapist to continually evaluate the client’s functional progress, the appropriateness of any OT intervention, and the utility of recommended adaptive equipment.

Main occupational therapy assessment for spinal cord injury includes:

  • Occupational profile: Client’s factors, context, and goals such as occupational history and life experiences, the pattern  of daily living, value interest and needs, current understanding of his/her problem
  • Sensation: Light touch, pinprick
  • Pain: Type, location, rating scale
  • Range of motion: Active and passive
  • Muscle strength: Tested by manual muscle testing
  • Grip and pinch strength
  • Muscle tone: Tested by modified Ashworth scale
  • Self-care: Functional assessment
  • Vision
  • Cognition
  • Psychosocial status: Client motivation, determination contexts
ASIA chart for spinal cord injury

General goals and objective of occupational therapy intervention with the individual with a spinal cord injury are as follows:

  • Maintain or increase range of motion and prevent problems associated with body function through the use of preparatory activity such as active and passive range of motion, splitting, positioning, and client education.
  • Increase the strength of muscle and address problem associated with their body function (examples sensation higher-level cognition psychosocial function) through the use of enabling and purposeful activities and occupations
  • Increase endurance and other performance skills through engagement in purposeful activities and occupations
  • Achieve the maximum level of independence in performance in all areas of occupation including ADL, work, play, and leisure
  • Help in psychosocial adjustment to disability
  • Evaluate recommend and educate the client in the use of necessary devices and adaptive devices according to the need of the patient
  • Ensure safety and independent home and environment accessibility through environmental modification where necessary
  • Develop clients communication skills necessary for training caregivers to provide safe assistance
  • Educate client, family members, and caregivers about the problematic condition

Occupational therapy intervention in spinal cord injury

Occupational therapist provides services throughout the whole treatment and Rehabilitation process for individuals with SCI.

Broadly we can categorize phases of recovery of patients with SCI into three categories:

spinal cord rehabilitation types phases

Acute Phase

Role of OT in spinal cord injury in acute care phase

  • Preventing joint integrity and mobility with positioning and early mobilization
  • Restoring function through self-care training
  • Education and training of family and caregivers

Positioning

  • Positioning of joint integrity and mobility includes and evaluation of total body positioning and hand is planting need.
  • For individual who is having tetraplegia to prevent range of motion limitation and shoulder pain the positioning should be- 

Intermittently positioned in 80 degree of shoulder abduction external rotation with scapular depression and full elbow extension

Splinting

  • Wrist and hand muscles are week then hand splint may be given
  • If wrist extension strength is less than three plus or 5 a splint that supports the wrist at neutral keeps thumb in opposition to maintain thumb web  space and allows finger to flex slightly at metacarpophalangeal MCP joint and proximal interphalangeal PIP joints should be used
  • If wrist extension strength is 3+/5 or greater short weeb space splint may be prescribed to maintain web space and support the thumb in opposition

Exercises

  • Passive active assisted and active range of motion of all all joints should be performed within strength ability and tolerance level
  • Light progressive resistive exercise may be given

Muscle re-education

  • This technique can be used when indicated for the wrist and elbows

Education

  • Family members and caregivers should be trained to assist with range of motion exercises splint use and skin inspection

Self-care and ADL

  • The client should be promoted to engage in self-care activities like feeding, maintaining hygiene, dressing using simple assistive devices such as a universal cuff or build-up handle.

Post-acute phase / inpatient rehabilitation

Patient with spinal cord injury after several month passed their initial injury are likely to be developed secondary complications such as pressure ulcers and joint contracture in these cases occupational therapist may introduce self management program.

In inpatient rehabilitation, OT in Spinal cord injury focuses on self-management skills such as being proactive, self-monitoring, and managing stress. These skills are important to independence for all individuals with SCI.

High tetraplegia/quadriplegia C1 to C4

The intervention and equipment needs of clients with high-level c-4 and above spinal cord injury are unique and extremely specialized.

Individual with C1to C3
  • Mainly affects sternomastoid, platysma, cervical paraspinal muscle
  • Clients are dependent on ventilator
  • Patients required total physical assistance from a caregiver to complete their daily activities
Individual with C4 level
  • Mainly affects upper trapezius and diaphragm
  • Initially dependent on ventilator and required total physical assistance from caregiver to complete ADL
  • Main progressed to breathing on their own
  • Clients may be able to use equipment for self-feeding
  • Individuals with a high level of tetraplegia develop of upright sitting endurance  when medical is stable
  • Educate client and family members about dependent pressure relief technique for static hypertension and proper body mechanics
  • Evaluate patient neck and ARM positioning in bed and in the wheelchair
  • Continue using hand splint to maintain available range of motion
  • Passive and active assisted active range of motion exercises is started for both neck and arms to maximize strength and to prevent undesirable contracture
  • Improve neck range of motion and inductance through the activities such as card game painting drawing page turning and typing
  • Assistive technology should be used to enhance performance skills such as typing with mouth stick to increase neck range of motion or at preparatory method and tasked used concurrently with occupations and activities like using a laptop with voice recognition software to complete homework assignment for school 
Tetraplegia (Quadriplegia)/High paraplegia (C5-T1)

The patient with C5 to T1 tetraplegia will require varying degree of caregive assistance.

C5 level involvement
  • Mainly includes deltoid and biceps
  • Patients which C5 involvement will dependent on caregivers for bed mobility.
  • Elbow extension and splint and \or pronation splint may be necessary to maintain range of motion as spasticity increases
  • Supportive splints should be provided for the wrist and hand
  • Upper body management will include a daily passive and active-assisted range of motion and activities to maximize strength
  • Mobile arm support should be used to extend weak shoulder and elbow flexion and to increase independence in the desired tasks
  • Adaptive equipment with C5 involvement includes wrist support used in conjunction with a universal cuff, scoop dish, long straw, long-handled utensils, long-handled comb/brush, wrist support, and mobile arm support.
C6 level involvement
  • C6 level includes the extensor carpi radialis brevis, extensor carpi radialis longus, clavicular pectrolis and serratus anterior
  • Wrist extension should be strengthened to maximize natural tendinosis function
  • Patients who have decreased moment may use a wrist-driven wrist/hand orthosis sometimes known as tendinosis hand splint to properly position their fingers for palmar prehension or a three-jaw chuck pinch  (thumb with index and middle finger).
  • Neuromuscular electrical stimulation can also be given to a strengthened weak wrist extensors
  • Adaptive equipment for C6 level involvement includes a universal Cuff scoop dish, built up utensil, and buttonhook
Individual with C7-T1 involvement
  • Patients with C7- T1 involvement show greater independence with self-care task and mobility
  • The key muscle at the C7 level includes triceps and latissimus dorsi
  • Key muscles at the C8-T11 level includes flexor carpi radialis, extrinsic thumb and finger muscles, and intrinsic thumb and finger muscles
  • Upper body management for the individual with C6-T1 level of injury includes strengthening  through a variety of methods such as the use of occupation, activities, preparatory methods, and preparatory tasks
  • Progressive resistive exercise and resistive activities should be used
  • Shoulder muscle should be strengthened so as to promote proximal stability
  • Intrinsic and extensive hand muscles should be strengthened  to create a stronger grasp and pinch

Principle of energy conservation techniques should be implemented for individual with C5-T1 tetraplegia.

Paraplegia (T2-T12, L1-L5)
  • Individual with paraplegia have normal head neck and upper extremity functioning
  • The rate of pregnancies also vary in patients patients with T2-T9 paraplegia have weak or not runkle control which affects their setting balance, reach and ability to control  bimanual activities
  • Patients with T10 to t12 and L1 to L5 paraplegia have good trunk control and have a better base of support with increased stability and an increased ability to perform bimanual activities
  • Adaptive equipment such as dressing stick, sock-aid aur leg lifter may initially be provided
  • Solder preservation strategy should be implemented in the treatment process of patients with paraplegia

Incomplete SCI/Clinical syndrome

  • For individual with an incomplete SCI motor function return will be greater and occur over a longer period of time
  • Prevent shoulder subluxation when patient is standing or ambulating
  • Supportive devices such as slings should be provided to support the shoulder
  • Neuromuscular electrical stimulation can be used to strengthen muscle

Outpatient rehabilitation phase

  • Evaluation and exploration of the vocational potential of the patients with SCI
  • Improve person’s attention span concentration, problem-solving ability judgment, and other high-level cognitive function
  • The occupational therapist may provide psychosocial support throughout the inpatient and outpatient Rehabilitation phase by allowing and increasing clients to express frustration anger fear and concerns
  • OT in spinal cord injury can provide training in stress management coping skills training and education regarding social connectedness, sexuality, relationship building strategy, and connection between occupation and emotional health 
References
  1. American Chronic Pain Association
  2. American Occupational Therapy Association
  3. American Occupational Therapy Association. Occupational therapy practice framework: domain and process, ed 3. Am J Occupational Therapy, 2014
  4. American Spinal Injury Association (ASIA)
  5. Meade M. Facilitating health mechanics: a guide for care providers of individuals with spinal cord injury and disease.
  6. Willard and Spackman’s Occupational therapy 6th edition
  7. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction by Heidi McHugh Pendleton PhD OTR/L FAOTA (Author), Winifred Schultz-Krohn PhD OTR/L BCP SWC FAOTA (Author)

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