4/23/2017

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Self-Care after Spinal Cord Injury

Matthew Blinky, OTR/L

Danielle Karhut, OTR/L

Briana Kelly, OTR/L

Barbara Zerbee, COTA/L

American Spinal Injury Association (ASIA)Impairment Scale

• AIS A- COMPLETE

• No motor or sensory function is preserved S4-S5

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• AIS B-INCOMPLETE

• Sensory function is preserved below level of injury (including S4-5)

• AIS C-INCOMPLETE

• At least ½ key muscles below level of injury <3/5

• AIS D-INCOMPLETE

• At least ½ key muscles below level of injury >3/5

• AIS E-NORMAL

• Motor and sensory function is normal

Tetraplegia (quadriplegia)

CERVICAL INJURY UE & LE affected

Sensory and/or motor impairment

Impairment varies with complete vs. incomplete injury

C4: Diaphragm, trapezius: Respiration

C5: Biceps: Elbow Flexion

C6: Radial wrist extensors: Wrist Extension

C7:Triceps: Elbow Extension

C8: Flexor digitorum: Finger Flexion

Paraplegia

THORACIC, LUMBAR, SACRAL INJURY Trunk & LE affected

Sensory and/or motor impairment

Impairment varies with complete vs. incomplete injury

L2: Psoas Major: Hip Flexion

L3: Quadriceps : Knee extension

L4: Tibialis Anterior: Ankle Flexion

L5: Extensor Hallicus Longus: Great Toe Extension

S1:Gastroc: Plantarflexion

S3-S5: Bowel & bladder

Determining Intervention Plan

Remediate vs. Compensate ? Considerations

Level of injury, complete vs incomplete

Endurance & prior activity level

Age

Caregiver quality/availability

Body habitus

Co-morbid conditions

Pain

Motivation

Prognosis

Activities of Daily Living

“Depending on the patients’ level of injury andscope of other complicating factors and medicalissues, independence in some activities may notbe possible.

In addition, patients need to weigh benefits ofindependence in contrast to time and energythat it may take to complete certain tasks.”

AOTA SCI Practice Guidelines

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What does the research show?

Perceived quality of life has negative effect on secondary conditions (Hammell, 2010)

After a significant life change (SCI), adults often transition from self-directed learners to dependent learners. (Pryor, 2004). Dependent learners require very specific education materials to increase their ability to learn and retain new information.

Start caregiver training asap and continue past discharge, linking clients to social networks for support, to increase adaptation to disability (Nogueira, 2012).

Measuring caregiver distress can be difficult - tools are being developed to focus on caregiver burden (Charlifue, 2016).

Framework for Health & Disability: WHO ICF

Basic Activities of Daily Living

Eating

Grooming

Bathing

Dressing

Toileting

Eating

Important goal for patients with high-level injury

Consider aspiration precautions

Options for adaptive equipment

Muscle groups C5: Biceps: Elbow Flexion

C6: Radial wrist extensors: Wrist Extension

C7:Triceps: Elbow Extension

C8: Flexor digitorum: Finger Flexion

Grooming Wash face & hands, shave, apply makeup, oral care, hair care

Important goal for patients with high-level injury

Consider QOL, confidence

Oral hygiene prevents pneumonia!

Muscle groups C5: Biceps: Elbow Flexion

C6: Radial wrist extensors: Wrist Extension

C7:Triceps: Elbow Extension

C8: Flexor digitorum: Finger Flexion

Tenodesis

Technique used with C6 injury Use of wrist extension to elicit “grasp”

Treatment goal: Strengthen wrist extensors Caution: Maintain flexor tension

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Bathing

DME

rolling shower commode chair

extended tub bench

tub seat (options: padded, seat cut-out)

grab bar

Assistive Devices

long-handled sponge

wash mitt

soap in stocking

hand held shower

Proper skin care & hygiene prevents:• Skin breakdown• Wounds• UTI

Dressing Consider post-injury precautions Position: Sit in w/c, lay in bed, on commode ‘Para-style technique’ for LB dressing

Long sit, head of bed elevated, tailor sit Adaptive equipment

Reacher - elastic shoelaces - button hook

Muscle Groups L2: Psoas Major: Hip Flexion L3: Quadriceps : Knee extension L4: Tibialis Anterior: Ankle Flexion L5: Extensor Hallicus Longus: Great Toe Extension S1:Gastroc: Plantarflexion

https://www.youtube.com/watch?v=FcBfGNLhY7c

https://www.youtube.com/watch?v=kMlulsywR6E

Toileting

Management of clothing and hygiene Continent vs. incontinent vs. accident Where? Consider transfer Cath, bowel program Caregiver training

Caregiver Training Safe body mechanics

Client directs care

Goal: “Self-direction of care”

Caregiver can practice on staff first

Self-care focus areas: depends on level of care

Toileting, B/B, safe handling

Trial various surfaces to ensure caregiver competency

Toilet, tub, couch, car, floor

Safety education

Pressure relief & skin checks

Autonomic dysreflexia

Acute Injury Considerations“Acute medical management of people with SCI focuses on minimizing further neurological damage to the spinal cord and optimizing recovery. Stability of the spine is clearly a priority” (Harvey, 2016)

Medical InterventionOperative

Immobilization

Comfort

Healing

Surgeon specific

Non-Surgical

Spine immobilization

Stabilization

Orthotics and BracingCervical

Philadelphia

Miami J

Aspen

Soft

Thoracic

TLSO

CTO

Lumbar

LSO

Precautions

Basic Spine Injury Precautions

NO Bending

NO Lifting

NO Twisting

*Additional Cervical Precaution No shoulder flexion/ abduction past 90*

Acute Phase: Strict!

CTLS

Log roll

Don brace in supine - prior to OOB

Bedrest = BEDREST!

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Common Splints and Braces

Acute UE

Wrist cock up

Resting hand

Elbow extension splints

Acute LE

Multipodus or PRAFO

Bunny boots

Foot-drop stops

Rehab and beyond

PRAFO

HKFO, KAFO, AFO

Elbow extension splints

Dorsal wrist splints

Tenodesis Splints

Acute Care Goals and Interdisciplinary Intervention

Precaution Education for patient, family, team members

Brace donning/ doffing techniques

Nursing, patient, family

Positioning/Range of Motion: prevent wounds, contractures

Monitor vitals in response to activity and position

Splinting

Basic ADL

Basic transfer techniques

Educate on next level of care – what to expect

Barriers to Self-Care:Complications of SCI Autonomic Dysreflexia* Heterotopic Ossification Pressure Injuries Contractures Sensory deficits Neurogenic Bowel and Bladder Patient Education and carryover of Techniques

Barriers: Autonomic DysreflexiaNeurological level at T6 and aboveImbalance of reflex sympathetic discharge life-threatening hypertension

Symptoms: vision disturbances, irregular heartrate, trouble breathing, sweaty, stuffy nose, high blood pressure, pounding headache, flushed

Dangerous outcomes: severe hypertension, seizures, retinal hemorrhage, pulmonary edema, renal insufficiency, cerebral hemorrhage, death

Causes: stimulus, pain, or irritation below level of injury

-Bladder or Bowel irritation

-Constrictive clothing

-Skin issues (calculus, ingrown toenail, pressure ulcers, burns, scrotal compression)

-UTI, illness, injury (fracture)

-Temperature fluctuations

-Sexual intercourse

Prevention: B&B routine, skin checks, stay diligent!

Barriers to Self-CareBody Habitus

Lower body dressing

Bowel & bladder management

Bed mobility

Age

Older clients: endurance, co-morbid conditions

Younger clients: maturity level, understanding of situation

Co-Morbid Conditions

Oncology patients

Substance abuse

Wounds

Sitting protocols

S/P flap or graft surgery

Size & location of wound

Pain

Incontinence

Prior to establishing a bladder program

Urinary retention

Frequency

Fluid restrictions may be required

Activities to Improve Self-Care Skills Sitting balance: EOM, long sit, w/c level

Table top activity Balloon tap – support self with one UE

Ball toss with B UE

Hit balloon with Therabar Functional reaching (various heights)

Forward leans-w/c level (pressure relief)

Lateral leans – EOM Long sit

LE management tailor sit/ figure 4

equipment dressing stick/ leg lifter Functional reaching forward

ROM arc (‘long-ways’)

Game or activity

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Environmental Modifications

Purpose: compensate for limitations that are unable to be immediately remediated

Structural changes to home or environment

Durable Medical Equipment

Adaptive Equipment

THE BIG QUESTION … What bathroom DME is covered?

Durable Medical Equipment:

Any specialized piece of medical equipment that a physician prescribes for use at home

It must be needed for a long term period

‘Long term’ was not defined

Be medically necessary and not useful to someone who is not sick or injured

Will not cover anything that is a permanent or physical modification to the home

i.e. Raised toilets, shower stalls, grab bars, stair glides or ramp

Limitations to obtain DME

Medicare “Rules” - pun intended!

Guideline changes made in early 1980s

Goal to decrease fraud: high incidence 1970-1980’s

Most insurances follow MEDICARE Guidelines

Not covered if used inside the bathroom walls

Bathroom DME is considered:

“a convenience”

“not medically necessary”

“no one has ever died from needing to sponge bathe”

Justifications to obtain DME

Define what is truly ‘medically necessary’ vs. what ‘just makes life easier’

Argue that bathing is medically necessary with the growing rate of MRSA, VRE & other super bugs that thrive on skin and take the opportunity to fester with any type of skin breakdown or abrasion

Can argue the need for shoulder preservation when recommending a shower/ commode chair

Medicare vs Medicaid Both government funded, both established in 1965

MEDICARE – federally funded along with population paying into the trust Regardless of income

At least one of the following:

65 yo+ Severe disability

On dialysis MEDICAID – aka DPA or MA

State and federally funded programs

Specific to the state

Generally low income persons of any age but must meet qualification

Be Creative!Not restricted to Medicare Guideline Limits Medicaid/ Medical Assistance Plans

Straight DPA

Covers tub seats/ benches

BSC / DABSC with script or authorization but NOT padded

Med Plus/ Unison

Covers some bathroom DME with script or authorization except Padded DABSC

Gateway / MA

Does not cover tub DME

Covers most BSC except padded DABSC

Gateway Straight

Covers most bathroom DME with a script except padded DABSC

UPMC for You

Covers most bathroom DME

Qualify for Padded items with a hx of pressure ulcers

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Be Creative!Not restricted to Medicare Guideline Limits

Private Insurances Security Blue

Covers some bathroom DME with script or authorization except padded DABSC

Highmark PPO Covers most BSC except padded DABSC

HA/Advantage Covers most BSC except padded DABSC

UPMC Health Plan Plan specific - too many plans to generalize

Cigna Does not cover tub DME Covers most BSC and padded DABSC

Aetna HMO or Traditional HMO- only covers BSC Traditional - covers much more if deemed a medical necessity and

with a script

Be Creative!Not restricted to Medicare Guideline Limits

Grants and Foundations

Travis Roy Foundations - SCI from an Accident

Assists with funds $2-5,000

Brighter Tomorrow Grant

MS Foundation gives up to $1,000

Must have diagnosed MS and be over 18

Elsie Bellows Fund- UCP Foundation

Must show financial information/demonstrate financial need and have no other funding sources

Loaner Closets

Churches, Muscular Dystrophy Association

How to find DME?

AMAZON

EBAY

Walmart

Local Drug stores,

Home Depot/ Lowes

Go! Mobility

Spin Life

Therapist writes LMN

Physician script

More costly if denied

Need to wait for approval

Self Pay Medical SupplierVendor Assisted

Assistive Technology

Switches Speaker phone, headset Mouthsticks iPad

Citations Charlifue, SB; Botticello, A; Kolakowsky-Hayner, SA; Richards, JS; & Tulsky, DS. (2016). Family caregivers of individuals

with spinal cord injury: exploring the stresses and benefits. Spinal Cord, 54, 732-736.

Hammell, K. (2010). Spinal cord injury rehabilitation research: patient priorities, current deficiencies and potential directions. Disability and Rehabilitation, 31(14), 1209-1218.

Harvey, LA (2016). Physiotherapy rehabilitation for people with spinal cord injuries. Journal of Physiotherapy, 62, 4-11.

Nogueira, PC; Rabeh, SAN; Carliri, MHL; Dantas, RAS; Haas, VJ. (2012). Burden of care and its impact on health-related quality of life of caregivers of individuals with spinal cord injury. Rev. Latino-Am. Enfermagem. 20(6), 1048-56.

Pryor, J. & Jannings, W. (2004). Preparing patients to self-manage faecal continence following spinal cord injury. International Journal of Therapy and Rehabilitation, 11(2), 79-82.

Rodakowski, J; Skidmore, E; Rogers, J; Schulz, R. (2013). Does social support impact depression in caregivers of adults ageing with spinal cord injuries? Clinical Rehab, 27(6), 565-575.

Sullivan, MP; Torres, SJ; Mehta, S; Ahn, J. (2013). Heterotopic ossification after central nervous system trauma. Bone & Joint Research, 2(3), 51-57.

Taweel, WA; Seyam, R. (2015). Neurogenic bladder in spinal cord patients. Research and Reports in Urology, 7, 85-99.

http://www.who.int/classifications/icf/en/

http://aota.org

http://www.asia-spinalinjury.org/elearning/ISNCSCI.php

https://www.nscisc.uab.edu/Public/Facts%202016.pdf