OCTH 246 SCI ADL and Transfers

Young adult

Rehab criteria

• Medically stable

• Needing intensive interdisciplinary approach to rehab

• Able to progress & demonstrate measurable gains as result of skilled therapy

• Able to tolerate intensive therapy 3hrs/ day

• Needing daily physician management

• Needing 24hr nursing care

• Able & willing to participate

• If care needs are anticipated post-discharge, care partner identified & participates in POC

C1- C4 injury

• Muscles innervated: upper trapezius, diaphragm, cervical paraspinal muscles

• Movement: neck flexion, extension, rotation, scapular elevation, inspiration

• Weakness: paralysis of trunk, UE/LE, inability to cough, endurance and VC low, may require ventilator

Concerns in C1-C4 injury

• Patient’s ability to instruct

• Caregiver’s ability to safely demonstrate

• Independent repositioning via tech ca decrease burden of care

• Mobility- power wheelchair

• Technology management for environment

• Technology for communication

C1-C4 assist required

• Personal & home care

  • 24 hours attendant care

• Goal: able to instruct in all aspects of care

Bathing C6 and higher

• Chest strap

• Lateral trunk supports

• Padded seat

• Bottom cutout

C5 injury (between C4-C5)

• Muscles innervated: deltoids, biceps, brachialis, brachioradialis, partial serratus anterior & rhomboids

• Movement: shoulder flexion, abduction, extension; elbow flexion; supination; scapular adduction & abduction

• Weakness: absent elbow extension; pronation; wrist & hand movement; total paralysis of trunk & LE

Concerns in C5 injury

• Patient’s ability to instruct

• Caregiver’s ability to safely demonstrate

• Independently change body position via technology can decrease “burden of care”

• Environmental supports will enable independent set up and decrease “burden of care” - (arm supports, lights, music, doors, phone, temperature, etc.)

• Power wheelchair

C5- assist required

• Personal care 10 hours/ day

• Home care 6 hours/ day

• Able to instruct in all aspects of care

C6 injury (between C5-C6)

• Muscles innervated: clavicular pectoralis, extensor carpi radialis longus and brevis, serratus anterior, partial latissimus dorsi

• Movement: scapular protraction, some horizontal adduction; supination; radial wrist extension

• Weakness: absent wrist flexion; elbow extension, hand movement; total paralysis of trunk and LE

Concerns in C6 injury

• Independently don and doff adaptive equipment

• Ability to instruct

• Bed mobility

• Weight shift and position change in w/c

• Eating, hygiene (including menstruation), dressing, bowel and bladder care, transfers?

C6- assist required

• Personal care 6 hours/ day

• Some assist with meal preparation

• Total assist for all other homemaking

Musculoskeletal considerations in transfers

• Flexibility, strength, stability, pain

• Focus areas: shoulders, elbows, wrists, but also need LE flexibility

• Elongate trunk and preserve flexion tenodesis in wrists

Bladder management

Intermittent catheterization

– q 4-6 hours

Condom catheter

– Leg bag

Supra-pubic catheter

– Leg bag

Bladder Diversion

– 1 year post

Bowel management considerations

• Independent to total assist

• Transfer bath bench

• May need adaptive aids

Wheelchairs for long-term use

• Light, adjustable

• Power-assist wheels

• Tray with rim

Common driving equipment

• Steering orthosis

• Reduced effort steering systems

• Hand controls

• Adapted secondary controls (horn, turn signals, wipers, dimmer)

• E-brake extension

• Automatic transmission

• Wheelchair lift/ ramp accessible

• Wheelchair docking or locking system

• Power controls on driver’s seat (if not using wheelchair)

• Chest strap

C7 muscles innervated

• Latissimus dorsi

• Sternal pectoralis

• Triceps, pronator quardratus

• Extensor carpi ulnaris

• Flexor carpi radialis

• Extensor digitorum communis

C8 muscles innervated

• FDP; FDS

• Flexor/ extensor/ abductor pollicis

• Partial lumbricals

C7 and C8 assist required

• Personal care up to 6 hours/ day

• Independent bowel & bladder will significantly decrease burden of care

• Homecare 2 hours/ day

• Independent light meal preparation & homemaking, some to total assistance for complex meal prep and heavy housecleaning

• Adaptive devices as indicated

C7 and C8 expected fxl outcomes

• Movement: elbow extension; ulnar wrist extension, wrist flexion, finger flexion & extension, thumb flexion/ extension, abduction

• Weakness: paralysis of trunk & lower extremities, limited grasp, release & dexterity secondary to partial intrinsic muscles of the hand

C7 and C8 assistance required

• Personal care: independent

• Homemaking: 0-3 hours/day

• Independent w/ complex meal prep and light housekeeping

• Total to some assistance w/ heavy housekeeping

Cheat sheet

• C4 – shoulder shrug

• C5 –elbow flexion

• C6 – wrist extension

• C7 – elbow extension

• C8 – finger flexion

• T1 – all finger and thumb

T1 to T9 expected fxl outcomes

• Muscles innervated: hand & thumb intrinsics, lumbricals, internal & external intercostals, upper abdominals, erector spinae

• Movements: UE fully intact, limited trunk stability, edurance increased secondary to innervation of intercostals

• Weakness: lower trunk paralysis. Total LE paralysis

T1 to T9 assistance required

• Personal care: independent

• Homemaking: none to 2-3 hours/ day

• Independent w/ complex meal prep & light housekeeping

• Total to some assistance w/ heavy housekeeping

T10 to L1 (paraplegia) expected fxl outcomes

Muscles innervated: Intercostals, external obliques, rectus abdominis

Movement: good trunk stability

Weakness: paralysis of LE

L2 to S5 expected fxl outcomes

• Muscles: Fully intact abdominals and all other trunk muscles and, depending on level, some degree of hip flexors, extensors, abductors, adductors, knee flexors, extensors, ankle dorsiflexion, plantarflexion

• Movement: partial control of LE (wide range of ambulation potential)

• Weakness: partial paralysis LE, hips, knees, ankles, feet

L2 to S5 assistance required

• Homemaking: 0-1 hours/ day

• Independent all cooking and light housekeeping

• Independent personal care

Transfer considerations

• Precautions

• Pain

• How they will transfer

• How many people needed

• Equipment

• Who will transfer then back to bed

When to use slideboard?

• Learners

• Pts who can’t weight bear on legs or have BLE weakness or amputations

• UE weakness, paralysis, or can’t use UE to assist

• “Gap” between surfaces, e.g. car

Transfer preparation

• Position 30-45 degree angle from transfer surface

• Remove closest armrest, except in stand-pivot

• Swing away/ remove footrests

• Lock brakes

• Explain procedures

• Have pt help as much as possible

Steps for slideboard

• Lift leg closer to transfer surface

• Pt lean head to opposite side

• Place board mid-thigh to intergluteal fold

• End of board where you want pt to end up

• Pt leans forward and moves across board

• LIFT, don’t slide

• Use towel under bare skin