Management in SCI-49

8/6/2019 Management in SCI-49

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Management in SCI Piya Trevittaya 1

ManagementManagementininSpinal cordSpinal cord InjuryInjury

Piya TrevittayaPiya TrevittayaDepartment of Occupational TherapyDepartment of Occupational Therapy

Faculty of Associated Medical SciencesFaculty of Associated Medical SciencesChiang Mai UniversityChiang Mai University




33 Major Phases of theMajor Phases of themanagementmanagement

� Acute phase

From onset of injury until upright position wasallowed

� Subacute phase (Rehabilitation phase)

From upright position until discharge planning

� Community reintegration




Acute PhaseAcute Phase

� Medical aspectImmobilization of Traumatic Spine

±Cervical: mostly 12 weeks by± Tong traction

± Turning frame and bed± Halo (orthotic)

After 12 weeks, SOMI brace or soft collar willapply for other 4-6 weeks

±Thoracic and lumbar spine± Bed rest with log-roll technique

± Body jacket, Taylor or Jewett after surgery for atleast 3 months




Assessment during acute phase IAssessment during acute phase I

1. Respiratory assessment (PT)2. Skin assessment

a) Observation

b) Pulpation for hyperthermic area

Looking for a sign of excess pressure area

³red, warm, edema, or small open andcracked skin in bony prominent areas´

3. Sensory assessment4. MMT and ROM




Assessment during acute phase IIAssessment during acute phase II

5. Deep tendon reflex and toneassessment for innervation level

C 6 Biceps

C 7 TricepsL 3-4 Quadriceps

S 1 Gastrocnemius

6. Sacral sparing if there is an improvement

7. Functional assessment; FIM, Barthel Index




Treatment in acute phase ITreatment in acute phase I1. Respiratory management (PT)

can assist patient by using abdominal corset

2. Positioning of hand and ankle joint3. ROM exercise of all jointsExcept:

a). contradicted joints eg., trunk rotation and hipflex over 60 degrees with leg straight or flex 90degrees when both hip and knee flex should beavoidedb). Quadriplegia who will prepare for Tenodesisgrasping

**Patients require 120 degrees of hip flexionwith straight leg so hamstring must bestretched to allow hip motion (120 degrees)




Treatment in acute phase IITreatment in acute phase II

4. Selective strengthening to avoid unstablefractureAvoid exercise in the first two weeks:

Scapular and shoulder in quadriplegiaHip and trunk in paraplegia

Using:Bilateral UE activities to avoid rotation stress

Ant. Deltoid, shoulder extensor, biceps, wrist extensor , andpectoralis must be exercised in quadriplegia

All UE must exercise in paraplegia (Triceps, latissimus dorsi,scapular depressors)




Treatment in acute phase IIITreatment in acute phase III

5. Graduate in vertical position

±Using tile table with abdominal binderand elastic stockings (bandage) wraps

around legs±First, Tile head and then progressive tile

in bed and tile table

±Reclining wheelchair

±Monitor vital sign carefully




Primary concernPrimary concern

Expected Functional Outcomesare a key for treatment planning

Physical Examination in this phase has been conducted asin acute phase but emphasis on

�skin condition and caring skill

�ROM and MMT

�Functional skill and ADLs

�Endurance and Wheelchair propulsion




Treatment in Rehabilitation Phase ITreatment in Rehabilitation Phase I

� Respiratory (PT)

� Positioning to prevent deformity

� Mat programs

� UE & trunk strengthening

� Transferring skill

� ADL

� Wheelchair skill

� Ambulatory skill




Mat ProgramMat Program

Principle of mat program³Momentum´

Stability

Mobility

Skill

BilateralSymmetrical

Weight shiftAsymmetrical

Movement

Quality and SkillMovement




MomentumMomentum




Example of mat activitiesExample of mat activities

� Rolling: supine prone³Momentum of intact parts´

Flex neck in supine prone

Extend neck in prone supineSymmetric Bilat. Stretch hand in supine

and cross ankle

Prone




PicturePictureof of

rollingrolling




Example of mat activities IIExample of mat activities II

� Prone on elbow: scapular strength

Prone and place elbow close to trunk with hand nearshoulder

Push elbow down and lift upper trunk

Weight shift on each elbow

And anterior-posterior

One elbow weight bearing with activity

Precaution: excessive lordosis of lumbar curve




Picture of prone on elbowPicture of prone on elbow




Example of mat activities IIIExample of mat activities III

� Prone on hands: Ant. Deltoid & Pec. major

Prone on elbows

Prone on hands

Weight shift on each side and forward-backward

Push up

In paraplegic patients

Prepare for walking with crutch(hyperextension of hip and lumbar spine in swing through phase)

Precaution: excessive lumbar lordosis




Example of mat activities IVExample of mat activities IV

� Supine of elbows ³Prepare for bed activities and long sitting position´

Three common methods:

1. Supine to this position directly in case of intactabdominal muscle

2. ³ Hand wedge´ under hip or Hook in pocket orbelt and use biceps as prime mover

3. Side lying to this position use shoulder adductionas a prime mover

4. Pull-up in quadriplegia will increase biceps andshoulder flexor strength for wheelchair propulsion



Management in SCIPiya Trevittaya

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³Hook into pocket´ ³Hook into pocket´



Management in SCIPiya Trevittaya

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SittingSitting

� Long sitting� Short sitting (bedside)

� Cross-legs sitting

³Essential position for ADLs´

Posture depends on level of injury

� Erect trunk>> low thoracic level

� Flex trunk + forward head >>

low cervical and high thoracic level

� Poor posture >>> high cervical




Two basic methods for sittingTwo basic methods for sitting

� From prone on elbows

move to side lying and hook hand

under leg, then biceps are the keyfor lifting upper part

� From supine on elbows

weight shift from side to sideHowever, individual technique is the

best for each patient




Sitting from prone on elbows ISitting from prone on elbows I




From prone on elbows IIFrom prone on elbows II




From supine on elbowsFrom supine on elbows




Activities in sitting positionActivities in sitting position

� Maintain sitting position (staticsitting balance)

� Grading activities for training balance

±Decrease base of support±Single limb support

±Without support

±UE movement in space

� Sitting push-up for increase strength




QuadrupedQuadruped

� For paraplegia only� Prepare for ambulation

� First position for hip¶s weight bearing

� Facilitate lower trunk and hip control� Use prone on elbows and ³walk´

backward by hands

� Weight shift in all direction� Freeing one hand for activity




KneelingKneeling

� For paraplegia only� ³walk´ backward until sit on heels

� Facilitate hip and pelvis controls

� Promote upright position balance� Use low crutches for weight shift and

training dynamic balance in thisposition

� Apply activity to increase balance inthis position




TransferTransfer

� Most of patients have to use wheelchairfor ambulation

� Start as soon as sitting balance isadequate

� Variety of techniques but for paraplegiaand well-trained quadriplegia>>> slidingtransfer is the choice (with or withoutsliding board)

� Training for other elements of this activity(break lock, remove armrest, ects,.)




TransferringTransferringWheelchair FloorWheelchair Floor

� The most difficult part of transfer

� There are many techniques dependon patient¶s capacity and motivation

� Must begin with transferring ondifferent level (wheelchair to bed)

� Example of these techniques




Technique ITechnique I




Technique IITechnique II




Technique IIITechnique III




Wheelchair skillWheelchair skill

� Wheelchair propulsion±On the same level: backward & forward

±Turning: normal and minimal turningarea

±doorways

±Ramp

±Outdoor and uneven surface

± ³Wheelies´ (balance on rear wheel whilecasters are off the floor)

±Pressure release on wheelchair




Overcome the kerbOvercome the kerb




Up stairUp stair




Down stair IDown stair I




Down stair IIDown stair II




Down stair IIIDown stair III




Narrow pathwayNarrow pathway




Reintegration to communityReintegration to community

� Home visit� Home modification

� Work place modification

� Roles

� Community

� Information

� Helping resources

� Peer support

� Independent living (IL)

� NGOs & GOs� Vocational training centre

� Quality of life




Concept of Independent LivingConcept of Independent Living

Management in SCI-49

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