Obstacle Course Treatment Paper.

Running Head: CASE STUDY 1 Case Study. Jane: Pediatric Spinal Cord Injury/Inpatient Rehabilitation Yenifer Karpuz, Naylam De Leon, and Sheila Alvarez The Praxis Institute Professor Brinda Mehta OTA 200/201 2/14/2022 CASE STUDY 2 Primary and Secondary Medical Diagnoses The patient has been diagnosed with an incomplete C6 SCI resulting from a diving accident based on the case study. The likely primary medical diagnosis for the patient is spinal cord injury. This is damage to any part of the spinal canal. Spinal cord injury may result in incomplete or complete body paralysis depending on the level of injury. Incomplete Lesions known as paraplegia are characterized by some degree of preservation of the sensory or motor nerves below the lesion. Complete Lesion total paralysis and loss of sensation; interruption of ascending and descending nerve tracts below the level of the injury.

Medical professionals classify different spinal cord injuries based on which section of the spine they affect: ❖ Cervical; in this section, the cervical spine plays a crucial role in supporting the head and allowing head and neck movement, ❖ Thoracic; this portion of the spine runs from the shoulder level to the lower abdomen ❖ Lumbar; the lumbar portion of the spine plays a significant role in supporting the upper body’s weight and facilitating torso and leg movement, ❖ Sacral; the sacral portion of the spine, also referred to as the sacrum, is between the lumbar spine and tailbone (ASIA, 2011) Prognosis In patients with complete injuries, muscles in the zone of partial preservation strengthen, which may result in significant functional change.

CASE STUDY 3 Patients with incomplete injury have a better prognosis, and their recovery is less predictable in its pattern and outcome. Most motor and sensory recovery occur in the first 3 months after onset, and the rate of recovery is minimal after a year. It is important for the therapist to maintain hope while planning a realistic course of treatment.

For people who survive the first year after injury, the year with the highest mortality rates, life expectancy is only slightly less than for the able-bodied population. (Hoffman & FieldFote, 2009) Vital signs and symptoms associated with spinal cord injury are mild neurologic impairment, including numbness and tingling of the extremities or neck pain. It is a seriously incapacitating physical issue that requires significant clinical consideration and habitually leaves victims in horrifying agony. Key signs and symptoms associated with body paralysis include involuntary spasms, muscle atrophy, muscle weakness, pain, or numbness on the affected muscles, tingling and loss of sensation in hands, fingers, feet and toe and loss of bladder and bowel control.

At C6 injury the dermatome is affected section of skin where all the sensory nerves originate from a single spinal nerve root. Doctors can pinpoint where the spinal cord is injured by losing sensation in a specific dermatome. Sensation at the outer forearms down to the thumbs and part of the index fingers. ( Fawcett et al., 2007) American Spinal Injury Association This is a system of tests used to define and describe the extent and severity of a patient’s spinal cord injury and help determine future rehabilitation and recovery needs. It is ideally CASE STUDY 4 completed within 72 hours after the initial injury. The patient’s grade is based on how much sensation he or she can feel at multiple points on the body, as well as tests of motor function: *ASIA/ISCoS Exam Chart (ASIA Impairment Scale)

Grade A: Complete lack of motor and sensory function below the level of injury (including the anal area) Grade B: Some sensations below the level of the injury (including anal sensation) Grade C: Some muscle movement is spared below the level of injury, but 50 percent of the muscles below the level of injury cannot move against gravity. Grade D: Most (more than 50 percent) of the muscles that are spared below the level of injury are strong enough to move against gravity. Grade E: All neurologic function has returned. (ASIA, 2011) Causes of SCI are: ➢ Car Accidents, ➢ Falls, ➢ Sports injuries, ➢ Diving accidents, ➢ Gunshots, ➢ Diseases. Complications associated with SCI are: ➢ Skin breakdown, ➢ Autonomic Dysreflexia, ➢ Decreased Vital Capacity, CASE STUDY 5 ➢ Urinary tract infections, ➢ Hypothermia and Spasticity. During the OT treatment precautions include wear a cervical collar when out of bed for the duration of the rehabilitation stay, such as bowel and bladder dysfunction Formation of pressure sores and infections, the key to address all facets of the patient’s injury experience. (Alverzo et al., 2009) Individuals with injuries at the T6 level or above may developed Autonomic Dysreflexia – Potentially life-threatening condition caused by painful stimuli below the level of injury that the body cannot respond to because of non-functioning nerve cells (especially in people with complete tetraplegia).

Symptoms include painful headache due to a sudden increase in blood pressure, slowed heart rate, increased or abnormal sweating, red blotches on the skin and restlessness. It’s important to be alert for causes, such as an overfull bladder, impacted stool, infected pressure ulcers or even ingrown toenails. Orthostatic or Postural Hypotension In contrast to Autonomic Dysreflexia, in orthostatic hypotension a sudden drop in blood pressure occurs when a person assumes an upright position. Most common in patients with lesions at the T6 level and above. Caused by impaired autonomic regulation. Aggravated by prolonged bed rest. Symptoms include light-headedness, dizziness, may faint on moving from reclined too upright. Patients may benefit from wearing abdominal binders and elastic compression. (Alverzo et al., 2009) Moreover, the patient was diagnosed with a secondary medical diagnosis that includes tetraplegia and respiratory arrest. Tetraplegia, sometimes known as quadriplegia, is a word used to describe CASE STUDY 6 the inability to move the upper and lower sections of the body freely. The fingers, hands, arms, chest, legs, feet, and toes are commonly affected, however the head, neck, and shoulders may or may not be included. Key signs and symptoms associated with body paralysis include involuntary spasms, muscle atrophy, muscle weakness, and pain or numbness on the affected muscles (Deng et al., 2021). Respiratory arrest is simply the absence of breathing which causes impairment of respiratory muscles, reduced vital capacity, ineffective cough, reduction in lung and chest wall compliance, and excess oxygen cost of breathing due to respiratory system distortion, is a major cause of morbidity and mortality in spinal cord injury (SCI). Individuals who are severely afflicted may require assistance with breathing. Respiratory complications, specifically pneumonia, have been identified as the leading cause of death in the first year of life after SCI. The severity of respiratory difficulties is determined by the degree of spinal cord injury and motor impairment. Up to 80% of patients with a spinal cord injury experience breathing difficulties during the initial period. (Consortium for Spinal Cord Medicine, 2006) Clinical Picture: Occupational Profile Jane is a 17-year-old girl recently graduated from high school who was diagnosed with incomplete C6 SCI due to a diving accident.

She is in an Inpatient Rehabilitation Center where she will begin therapies. Jane has a tracheostomy due to respiratory arrest and a Gastrostomy. OT will review the patient’s chart and make an evaluation based on all the information obtained from an interview that he will have with the patient and her family about their concerns and goals, as well as consulting the nurse for any spinal cord. precautions to be considered in future interventions and with Primary physician. It is also important for the therapist to know what a normal day in the life of the patient is like before the accident so that the OT can create routines, CASE STUDY 7 habits, and other activities for the patient. The Canadian Occupational Performance Measure (COPM) is an excellent tool. As the patient is a recently graduated high school teenager, we assume that she wants to continue her studies and that she has hobbies related to her age, such as using the telephone to talk with friends and visit social networks; this will be considered as patient’s goal when creating interventions. From the first encounter, the therapist also begins to educate the patient. Problem list: ➢ Incomplete C6 SCI due to diving accident. ➢ Paralyzed (tetraplegia). ➢ Intubated for airway protection. ➢ Emergency tracheostomy due to respiratory arrest. ➢ C5 corpectomy.

➢ Anterior and posterior spinal fusion with allograft and instrumentation. ➢ Gastrostomy. ➢ Decreased balance. ➢ Decreased fine motor skills (consists with her level of injury) ➢ Light touch sensation. ➢ Catheterization. ➢ Dependent bowel management. ➢ Maximum assistance is required for feeding, grooming, bathing, and dressing activities. (Maximum assistance for ADLS) ➢ Dependent for all functional mobility and transfers. CASE STUDY 8 Occupational Performance The OT will work as a team with all the professionals in charge of carrying out the recovery of the patient. The OT will likewise consider all the information of interest collected regarding the client’s home and environment, and her body functions and structures. The patient underwent the Asian test, which is The American Spinal Cord Association scale uses the classification for spinal cord injuries, where she was classified as level B (sensory incomplete). Spinal stability must be established prior to any physical contact with the patient.

The Manual Muscle Test will use to measure the strength and determine the functional level of the patient. Is important to evaluate Hand and Wrist for future ADLs treatments, its evaluation is both physical and functional. Client factor and Body Functions Physical intervention comprises bed and wheelchair placement, upper extremity splinting, daily upper extremity range of motion, and strengthening, just as it did in the acute recovery phase. Weights, pulley systems, skateboards, suspension slings, movable armrests, and modalities such as biofeedback, neuromuscular electrical stimulation, and robotics can all help with strengthening (Hill, 1986; Hoffman & Field-Fote, 2009) • Mental functions(strengths): Jane demonstrates excellent cognitive abilities. CASE STUDY • 9 Physical Functions(weaknesses): ➢ No active grasp ➢ Tenodesis ➢ Decreased balance and fine motor skills consist with her level of injury • Sensory Functions(weaknesses): ➢ Light touch sensation Obstacle Course Treatment Paper.

➢ Remaining spinal segments absent Areas of Occupation ❖ ADLs and IADLs: Jane is dependent for catheterization and bowel management, Maximum assistance is required for feeding, grooming, bathing, and dressing activities, and she is dependent for all functional mobility and transfers. ❖ Leisure and Sports: Now Jane has this affected area, but the therapist’s goals and treatment will also be based on what the patient likes to do so Jane will enjoy her recovery and she will carry it out with enthusiasm. Many patients today with this same disease have been able to resume the practice of sports and recreational activities, which are so important for their age. ❖ School and Vocation: The patient is a recent high school graduate. If the patient wishes to continue her studies in college, the therapist will educate the teachers on how to work with her and the therapist will check that the center meets the universal requirements for patients with disabilities. Online classes are an option too

❖ Home and Community: Jane lives with her parents in Chicago, and she has many friends. Jane is now in a rehabilitation center but when she is transferred home the therapist will CASE STUDY 10 evaluate the place where she lives to determine positive and negative aspects to make the patient’s life easier and more independent. LONG TERM/SHORT TERM GOALS ❖ 1- LTG: The patient will demonstrate UE dressing pull over the t-shirts without back support and minimal assistance within 6 months 1- STG: The patient will be able to use a dress EZ dressing aid for UE to dress into a t-shirt with back support with moderate assistance in 3 months ❖ 2- LTG: The patient will be able to perform functional transfer from bed to the Wheelchair with minimal assistance within 6 months 2- STG: The patient will demonstrate the ability to use the slide board during bed-to wheelchair transfer with moderated assistance within 3 months ❖ 3- LTG: Jane will complete her oral care with minimal assistance within 6 months.

3 – STG: Jane will use assistive device such as an adaptive toothbrush holder to complete her oral care with moderate assistance within 3 months. ❖ 4 -LTG: She will engage LE dressing pull over her sports shorts in a sitting position with minimal assistance within 6 months. 4- STG: Jane will be able to use reaching to pull her shorts over in her backside in a lying position with moderate assistance within 3 months TREATMENTS CASE STUDY 11 First Treatment Session Time: 10 AM Place: in-patient rehabilitation facility Scenario: 1 hour divided into four 15-minute activities The four sections of the session are: 1- Introduction and training in UE range of motion (ROM) exercises. EX: ranging to facilitate tenodesis grasp – when the wrist is extended the finger are flexed – when de wrist is flexed, the fingers are extended 2-: Educate client how to don a pullover shirt, by putting a sleeve over one arm first. Obstacle Course Treatment Paper.

Dressing one arm at a time may be a good way of conserving energy and will give the client an adaptive technique to make it easier to 3- Educating the client in how to use a Reacher, so that the patient gains control and she can put on the shorts with an adaptive device. 4- Work on coordinated movement exercises (UE and LE) (moving from bed to wheelchair using the slide board) This will allow the patient a better coordination of arms and hips with the rest of the body. Second Treatment Session CASE STUDY 12 Time: 10 AM Place: in-patient rehabilitation facility Scenario: 1 hour divided into four 15-minute activities The four sections of the session are: 1- Explain to the client what exercises they are going to learn and perform a series of stretching routines that will help keep their joints flexible and, in the long run, improve their muscular strength for allow you to resume your favorite activities, including chatting with your friends and looking pretty 2- The patient lying on one side will use the rails of the bed and pull herself up to start getting up with maximal assistance. 3- Work in transfer from bed to wheelchair using the slide board 4- OTP prepared a surprise activity completing personal grooming, at this point Putting some juvenile music the patient begins to brush her teeth using a buildup toothbrush with moderate assist ance and the therapist will show her how using a wrist-driven wrist-hand orthosis makeup can be applied. Obstacle Course Treatment Paper.

Parent home program: Developing a trusting and collaborative relationship with families is a key ingredient for interventions success 1 – Parents will be educated about the illness presented by the patient, facilitating access to publications about it and allowing them to ask questions at any time that they have a doubt. CASE STUDY 13 2- The OTP will provide parents with detailed information about the therapeutic process that the patient will have and how to face and deal with complex factors of normal development coupled with new deficiencies and disabilities. 3-The OTP will teach the patient’s parents the use of adaptive equipment and the necessary techniques for their care, as well as preventive care techniques that may be better for the patient even though she has her own therapists. 4-It is very important that parents understand that they should not do everything for the patient, because the best help that parents can give the patient is to let her achieve degrees of independence. Summary Jane was diagnosed with spinal cord injury Incomplete at C6. This may significantly impact the quality of life of the patient.

As OT practitioners we address the needs of this patient, while also educating her family. Completing the assessment of ADLs, ROM, Strength, and Intervention Plan. For instance, we create short-term goals, long-term goals, treatments, and a parent home program with consideration of precautions to provide safe and effective rehabilitation. As such, it is essential to offer interventions that would enhance the patient`s quality of life. Hoping that the patient will live life to the fullest of her capacity. Obstacle Course Treatment Paper.

CASE STUDY 14 REFERENCES • Austin, P. D., Craig, A., Middleton, J. W., Tran, Y., Costa, D. S., Wrigley, P. J., & Siddall, P. J. (2021). The short-term effects of head-mounted virtual-reality on neuropathic pain intensity in people with spinal cord injury pain: a randomized cross-over pilot study. Spinal Cord, 59(7), 738-746. • Deng, Y., Yang, S., Zhao, H., Diao, Q., & Hou, C. (2021). IAPV-Induced Paralytic Symptoms Associated with Tachypnea via Impaired Tracheal System Function. International journal of molecular sciences, 22(18), 10078. • Ko, H. Y., & Huh, S. (2021). Functional Assessment and Expected Functional Outcomes Following Spinal Cord Injuries. In Handbook of Spinal Cord Injuries and Related Disorders (pp. 131-139). Springer, Singapore. • Placeres, A. F., Fiorati, R. C., Alonso, J. B., Carrijo, D. C. D. M., & Jesus, T. S. (2021). Depression or anxiety symptoms associated with occupational role transitions in Brazilian adults with a traumatic spinal cord injury: A multivariate analysis. Work, 68(4), 1009-1018. CASE STUDY 15