Exploration of Function and Exploration of Function and Identity after SCIIdentity after SCI

Raheleh Tschoepe MS, OT/LRaheleh Tschoepe MS, OT/LUNC Health CareUNC Health Care

Inpatient Rehabilitation UnitInpatient Rehabilitation UnitSCI TeamSCI Team

rtschoep@unch.unc.edurtschoep@unch.unc.edu919-966-1626919-966-1626

November 3, 2012November 3, 2012

ObjectivesObjectives• By the end of this session, you will have basic

understanding of: Incidence and etiology of SCI in the U.S. SCI injury levels, syndromes and the ASIA

Classification System – what do they tell us? How an interdisciplinary therapy team can

maximize functional independence How to recognize, prevent and address potential

barriers to progress across the continuum of care OT evaluation and treatment procedures,

discharge planning and integration into interdisciplinary treatment

Function and identity as guides to treatment planning

StatisticsStatistics

• Incidence: 12,000 new cases each year

• Prevalence: ~265,000 persons in the U.S. living with SCI

• Age - 1973-1979: 28.7 years old

Since 2005: 40.7 years old

• Gender: 80.7 % reported have been malewww.nscisc.uab.edu

Etiology• MVC: 40.4%

• Falls: 27.9%

• Violence: 15.0% (gunshot wounds)

• Sports: 8.0%

• Non-traumatic: 8.0% (disease, infection, congenital disability)

• Sports Fallswww.nscisc.uab.edu

Neurological Levels

• Incomplete tetraplegia (39.5%)

• Complete paraplegia (22.1%)

• Incomplete paraplegia (21.7%)

• Complete tetraplegia (16.3%)

www.nscisc.uab.edu

Length of stay and discharge• Acute care - 24 days

• Inpatient Rehab – 37 days

(greater for people with complete injuries)

• 89.9% discharge to a private residence

• 6.2% discharge to nursing homes

Is it enough to discharge at a “supervision” level?

www.nscisc.uab.edu

More than a number…

"I think a hero is an ordinary individual who finds strength to persevere and endure in

spite of overwhelming obstacles. “

-Christopher Reeve

Exploring Function

Occupational Therapy Practice Framework

Occupational therapy is:“..the application of an intervention process

that facilitates engagement in occupation to support participation in life…”

Occupational therapists and occupational therapy assistants:

“focus on assisting people to engage in daily life activities that they find meaningful and purposeful.”

Exploring Independence

OT’s Role

• Carolyn Baum defines independence as the ability to take responsibility for one's own role performance, needs and desires. In order to acknowledge the variety of ways individuals accomplish the necessary and desirable tasks in their lives, it is essential to embrace a broad view.

• The profession recognizes independence as a state of self-determination.

Baum, C. M. (2011). The John Stanley Coulter Memorial Lecture. Fulfilling the promise: Supporting participation in daily life. Archives of Physical Medicine and Rehabilitation, 92(2), 169-175.

OT’s Role applied to SCI• Spinal cord injury or disease can lead to

changes that are unanticipated, immediate and often permanent.

• Impairment or loss in motor, sensory function

• Result is a wide range of limitations in activities and participation.

Herrmann et al. (2011). The comprehensive ICF core sets for spinal cord injury from the perspective of occupational therapists: a worldwide validation study using the Delphi technique. Spinal Cord, 49, 600-613.

OT’s Role in SCI

• Problems are direct result of interaction between disease or injury sequelae and environmental and personal factors (contextual factors).

Biopsychoscial model

of the

International Classification of Functioning, Disability, and Health

OT’s Role in SCIICF component body functions

* Temperament and personality functions

* Energy and drive functions

* Sleep functions

* Vestibular functions

* Sensory functions related to pain, temperature, other stimuli

* Voice functions

* Increased/decreased blood pressure

* Mobility of joint functions

* Control and coordination of voluntary movement

OT’s Role in SCIICF component body structures

* Cervical, thoracic and lumbosacral spinal cord

* Cauda equina

* Spinal nerves

* Structure of eyes

* Urinary system structure

* Structure of UE, LE, trunk

* Bones, joints, muscles, skin of entire body

* Structure of head and neck

* Structure of respiratory and intestinal systems

OT’s Role in SCIICF component activities and participation examples:

* Religion and spirituality; socializing; political life

* Using telecommunication devices

* Changing basic body position

* Transferring oneself

* Pricking up, grasping, releasing manipulation

* Driving

* Washing body parts, drying oneself

* Sexual relationships

* Using household appliances

OT’s Role in SCIICF component environmental factor examples: * Food; drugs

* General assistive products and technology for personal use in daily living, education, employment

* Design, construction, and building products and technology for entering, exiting and gaining access to facilities

* Financial assets

* Immediate, extended family and friends

* Acquaintances, peers, colleagues, community members

Functional Recovery by Level

Barriers to Progress

Spinal Shock Pressure Ulcers DVT & PE Spasticity – benefit or hindrance? Limited ROM Contractures Neurological Shoulder: common in

tetraplegia Heterotopic Ossification (HO) Osteoporosis Orthostatic Hypotension

Barriers to Progress

Orthostatic Hypotension Autonomic Dysreflexia *Bladder Management *Bowel Program * Skin Issues Respiratory illness Most common cause of death is resp.

failure. Head Injury Psychosocial Adjustment

OT Evaluation: ICF Prior Level of Function * Body functions/Structures<>Activities<>Participation* Environmental factors, Personal Factors

Current level of function* Same as above* Musculoskeletal and neuromuscular assessment* Sensation (light touch, pin prick, proprioception)* Mobility (balance, synergy, coordination,

substitution)* Skin integrity, blood pressure, endurance* Psychosocial factors

Treatment along theTreatment along thecontinuum of carecontinuum of care

Working Together for a Working Together for a Successful Outcome:Successful Outcome:

Interdisciplinary ConceptsInterdisciplinary Concepts

Interdisciplinary ConceptsInterdisciplinary ConceptsI/ADL Progression is inextricably linked to PT,

RT, SLP, psychology, medicine and nursing concepts:

- ADLs at a wheelchair level– DME/AE selection– Mobility preparation and strategies– Transfers to BSC, TTB, shower chair, standard bed,

couch, dining room chair– Bowel/bladder management (education &

technique)– Sexuality education– Instrumental Activities of Daily Living– Client’s ability to direct his/her care– SCI Education

Progressing ADL’sADL Hallmark

level/expected outcomes

Intervention Tips/Tricks

Eating/Groomig

C5: set up with AE

C6: set up with or without AE (Tenodesis)

C7/C8: indep with time or AE

T1 and lower – indep

-dorsal wrist support with u-cuff-univ cuff-non-skid material-long straw, cup with univ handle-built up handles and tenodesis-mobile arm support

-wash mitt-electric toothbrush/razor- Automatic dispensers

-upright positions with elbows supported

-Progress based on food consistency/type &preferred foods

-C or D handles to maximize handling

-lever handles

ADL’s - ProgressionADL Hallmark

level/expected outcomes

Intervention Tips/Tricks

Bathing C5: max A to dependent

C6: min to max A (Tenodesis)

C7/C8: mod A to indep

T1 and lower – indep

- long handle sponge

- Soap on a rope- Hand held

shower heads- Grab bars - wash mitt- electric

toothbrush/razor- Automatic

dispensers

- Lever handles

-Combine bathing/toileting tasks

-Monitor water temperature and blood pressure

ADL’s - ProgressionADL Hallmark

level/expected outcomes

Intervention Tips/Tricks

Dressing C5: mod A to dependent

C6: mod I to max A (Tenodesis)

C7/C8: mod I

T1 and lower – indep

- Button/Zipper hook- Dressing sticks,

sock aides, reacher

- Leg straps- Bed ladder- Supine in bed;

Long sit; ring sit; rolling; in wheelchair (wc)

- Progress surface types (firm to soft)

- Progress body mechanics

- Backwards/forwards chaining

- Over-practice to assure functional carry-over

- Encourage progression to wc level

Bowel and BladderEquipment Selection

Do your homework and advocate!Important considerations:

Basic Complex

Tub Transfer Bench vs. Shower Chair

Tile in Space vs. Recline

Standard vs. Bariatric Cut out location/need

Drop Arm vs. Fixed Wheeled

Padding vs. Hard Surface Padding vs. Hard Surface

Drop Arm vs. Fixed

Bladder Management

Program type - UMN vs. LMN•Intermittent: bag kits, straight catheters, antibacterial, pre-lubricated•Indwelling: leg bag, Foley bag (aesthetics, modesty)•Catheterization schedule: habits, roles, routines•Keys to success: consistency, hydration, activity, support system

Adaptive Equipment•mirrors, inserters, spreaders, holders, clothing/environmental modification

Positioning

Education

Bowel Management

Program type - UMN vs. LMNSchedule - habits, roles, routines

- consistency, diet, activity, support system

DME/Adaptive Equipment - mirrors, inserters, stimulators, environmental modification

Positioning

- bed vs. bedside commode vs. shower vs. standard toilet

Education

Sexuality P-LI-SS-IT model

Permission Limited Information Specific Suggestions (OT’s STOP here) Intensive Therapy

Educate on the facts & provide information on: adaptation positioning for security comfort and trunk control Refer to physician for potential medical

interventionsTaylor, B. & Davis, S. (2006). Using the extended PLISSIT model to address sexual

healthcare needs. Nov. 22-28; 21(11) 35-40.

Sexuality SCI may result in heightened, decreased, or lack of

sensation and perception in various dermatomes. Encourage patients to:

explore themselves physically and identify these changes, discuss with therapists and physicians when there are questions

communicate changes with their partner and be open to multiple forms of sexual stimulation.

Consider psychosocial history and current issues – refer as appropriate to other disciplines

Another ADL: a relearning process –

How does the person view their roles, responsibilities and participation?

Management of the Management of the Neurological ShoulderNeurological Shoulder

Coordination of Muscle Synergies SCI results in inability to coordinate isometric,

eccentric, and concentric muscle contractions SCI results in inability to control speed and

direction As a result, clinical presentation often shows

“all or nothing” Upper extremity preservation/protection

Betz, Kendra. Contemporary Forums Spinal Cord Injury Conference: Upper Extremity Pain and Injury: Interdisciplinary Approaches for Prevention and Treatment. San Francisco, 2008.

Aging & SCI Considerations for acute SCI in older adults

Mental flexibility/adaptability

Pre-existing body structure/function issues

Support systems

Resources/ability to make modifications

Considerations for older adults with chronic SCI Life expectancy with paraplegia – similar to that of able

bodied adults; tetraplegia – reduced by 10%

Exacerbated musculoskeletal, respiratory, urinary symptoms

May benefit from more assistance, home modifications, AE/AD/DME

Harvey, L. (2008). Management of Spinal Cord Injuries

Applying what we know…

“I’ve learned that people will forget what you said, people will forget

what you did, but people will never forget how you made them feel.” ~Maya Angelou

HOW do we define function and independence?

• ROM• Strength• FIM scores: ADL’s, transfers, mobility• International Classification of Functioning:

“positive overall health condition”• AOTA: Living Life to its Fullest

CLIENT GOALS

“…a state of self determination.”

WHO defines function and independence?

• John:

40 year old OT with 15 years of SCI experience. Works 50 hours/week on an inpatient SCI unit.

• Melanie:

20 year old in roll over MVC 2 weeks ago with resulting T10 ASIA A SCI.

Therapy is…

…an interactive, interpersonal experience.

It is the therapist’s responsibility and skill to read between the lines

Have we taken into account:

Purpose, goals, routines, meaning, drive, desires, fears, world view, context, etc?

Case Study - Jason

• 31 yo male, injured in bike racing accident

• IBM employee

• Required to d/c from AIR at modified independent level

• He blogged his entire rehab journey and continues to blog on a regular basis

• The following are some quotes reflecting his rehab experience

Lessons from a Rehab BlogOccupational Therapy

“Occupational therapy teaches you how to do pretty much anything you need to do to live your life. Lately, whenever the therapists ask me to do something a normal person would do, like open a door or push an elevator button, I say, "It's occupational!". 

“Speaking of food, my occupational therapist, is going to teach me to make brownies on Friday.  Ghirardelli brownies no less.  Earlier this week, they taught me to make a bed, vacuum a carpet, and do laundry.  All good stuff to know.  All 10 times harder than it is for walkers.”

Lessons from a rehab blog OT in context: Purpose/Meaning “Work is going about as well as it could.  I'm still

working 3 hours a day, and I think it's getting easier.  I'm still glad I'm doing it.  It makes me feel like I'm accomplishing something.  It's about the only time I feel useful.”

“Gus continues to make himself indispensable.  Last weekend, we took my van over to his house to do a little work on it.  I really appreciate that, but it's frustrating to watch him do work that I used to be perfectly capable of doing myself.  Makes me feel useless.”

Lessons from a rehab blogIndependence gets a whole new meaning

“……they say it means that I will eventually be able to regain almost complete independence.  It's hard to imagine right now how I'm going to get to that point since right now, I can't even sit up on my own, but for now I'm willing to trust that it's true.”

• “I take solace in the fact that I've met people who have lived in chairs for decades, and they have obviously figured all this stuff out, but I'm still getting a little nervous about whether, and when I'll figure it all out.”

Lessons from a rehab blogReality of discharge, necessity of routine

“That knowledge and my short countdown to release has me worried.  There's still a LOT I can't do on my own.  It's hard to imagine I'm going to master all of it in the next three weeks. I'm going to have to use some of those skills to survive in my apartment.  Transferring from my wheelchair into the shower is just one example of a daily activity that requires a tremendous amount of strength and balance, and which has a lot of opportunity for painful failure.  I've only done it once successfully, and the shower in here is much larger, and I had two spotters.”

What it all means…

• Teamwork & communication through the continuum of care and stages of recovery impacts outcomes

• Success is dependent on a good foundation• A good foundation is based on listening.• Bio-psycho-social model indicates all 3 are critical

and must all be investigated and integrated• Therapists must facilitate development of a reliable,

comfortable and patient-driven routine. Then practice, practice, practice.

• We bridge the gap from injury to recovery through training, education, and support…EMPOWERMENT

References• Harvey, L. (2008). Management of Spinal Cord Injuries• Consortium for Spinal Cord Medicine. Preserving Upper Limb Function Following Spinal

Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Paralyzed Veterans Association. 2005. Available for free at: www.pva.org

• Lindsey L, Klebine P, Wells MJ. Understanding Spinal Cord Injury and Functional Goals. Birmingham, AL: Office of Research Services, University of Alabama at Birmingham, 2000.

• O’Sullivan S, Schmitz T. Physical Rehabilitation: Assessment and Treatment. Philadelphia: F.A. Davis Company, 2001.

• Somers, M. Functional Rehabilitation of Spinal Cord Injury. Norwalk, CT: Appleton & Lange, 2002.

• Musick, Darrell. Contemporary Forums Spinal Cord Injury Conference: Mobility Progression for Spinal Cord Injury. Las Vegas, 2006.

• Betz, Kendra. Contemporary Forums Spinal Cord Injury Conference: Upper Extremity Pain and Injury: Interdisciplinary Approaches for Prevention and Treatment. San Francisco, 2008.

• McKinley, W.,Santoa, K., Meade, M., Brooke, K., "Incidence and Outcomes of Spinal Cord Injury Clinical Synromes", The Journal of Spinal Cord Medicine, 30(3): 215-224, January 2007.

• Hutchinson, S., Loy, D., Kleiber, D., Dattilo, J., “Leisure as a Coping Resource: Variations in Coping with Traumatic Injury and Illness”, Leisure Sciences, 25: 143-161, 2003.

• O’Brian, A., Renwick, R., Yoshida, K., “Leisure participation for individuals living with acquired spinal cord injury”, International Journal of Rehabilitation Research, 31 (3), 2008.

References• Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for

Health-Care Professionals. Consortium for Spinal Cord Medicine: Clinical Practice Guidelines. July 1999

• Herrmann et al. (2011). The comprehensive ICF core sets for spinal cord injury from the perspective of occupational therapists: a worldwide validation study using the Delphi technique. Spinal Cord, 49, 600-613.

Spinal Cord Injury Educational Resources

• National Spinal Cord Injury Association (NSCIA):– association that promotes independence, health and well being of individuals

with spinal cord injury and disease through a free help-line, an on-line forum, nationwide chapters and support groups.

– Website: www.spinalcord.org

• Paralyzed Veterans of America (PVA): – offers numerous publications, fact sheets and authoritative clinical guidelines

for SCI (in English and Spanish) and supports research by way of its Spinal Cord Research Foundation.

– Website: www.pva.org

• Spinal Cord Injury Information Network: – Rich source of information on all topics related to SCI including medicine,

liffestyle, religion, advocacy & technology – Website: www.spinalcord.uab.edu

• Christopher and Dana Reeve Paralysis Resource Center (PRC): – a program created to provide a comprehensive information source for people

living with paralysis and their caregivers to promote health, community involvement and quality of life.

– Website: www.paralysis.org

• The University of Miami School of Medicine– Offers an easy to use online manual on spinal cord injury health

and wellness– Website: http://calder.med.miami.edu.pointis/index.html

• The University of Washington School of Medicine:– Maintains a useful website with information on skin care, bowel

and bladder management and other topics of concern for people with spinal cord injuries

– Website: http://Depts.washington.edu/rehab/

• Craig Hospital:– Located near Denver, specializes in the rehabiliation of SCI and

TBI. Federally-supported educational materials are available online to help survivors maintain health and wellness. Emphasis on issues related to aging with a disability

– Website: www.craighospital.org/default.asp (click on “spinal cord injury” then “health and wellness”

Spinal Cord Injury Educational Resources

• North Carolina Office on Disability and Health:– Promotes the health and wellness of people with disability in North Carolina

through an integrated program of polocies, programs and research– Website: www.fpg.unc.edu/%7Encodh/index.htm

• Shepherd Center: – Key to Independence Workbook– Website: www.shepherd.org

• Take Control:– A multi-media guide to SCI– Website: www.pdassoc.com

North Carolina Spinal Cord Injury Association- http://www.ncscia.org/

Spinal Cord Injury Educational Resources