SPINAL CORD INJURYNEIL BARRY

USI: 1009842

BACKGROUND

• PATIENT PRESENTED WITH SPINAL CORD INJURY, WHEELCHAIR BOUND, INTERVIEWED ON INCLINE TABLE (IN NEUTRAL POSITION) IN SUPINE WITH URINARY CATHETER ATTACHED.

• THE PATIENT USES A WHEELCHAIR BUT NO OTHER ASSISTIVE DEVICE

PATIENT INFORMATION

• INITIALS: M.G.

• ADDRESS: 213 GROVE E.B.D

• D.O.B: 02/10/73

• SEX: MALE

• HANDEDNESS: RIGHT

• SOCIAL HISTORY: CURRENTLY UNABLE TO WORK, LIVES WITH FAMILY MEMBERS ON BOTTOM FLAT.

• CONSUMES ALCOHOL.

• REFERRED BY: SOPD, SEEN AT THE PALMS REHAB CENTRE

FUNCTIONAL STATUS

• IS CURRENTLY ABLE TO USE 5LB DUMBELLS FOR U.E. EXERCISES

• UNABLE TO SIT UNASSISTED FROM A LYING POSITION, AND UNABLE TO TRANSFER FROM BED-CHAIR UNASSISTED.

• APART FROM EATING, THE PT. IS UNABLE TO GROOM/ SELF CARE WITHOUT ASSISTANCE, BUT HAS A MEASURE OF BOWEL CONTROL WITH NOTABLE OCCURANCE OF DIARRHOEA ONCE WITHIN THE PAST 6 MONTHS.

FAMILY HISTORY/PAST MEDICAL HISTORY

• MOTHER HAD HEART BYPASS SURGERY

• PATIENT SUFFERRED A MINOR ISCHEMIC STROKE APPROX. 1 YEAR PRIOR TO INCIDENT.

CURRENT MEDICAL HISTORY

• PATIENT REPORTED THAT HE WAS RIDING A BICYCLE, WHEN HE COLLIDED WITH ANOTHER AND FELL INTO A DRAIN, AFTER WHICH HE COULD NOT FEEL HIS LEGS. HE SAID HE UNDERWENT SURGERY TO HIS SPINE MORE THAN 6 MONTHS AGO.

• FURTHER INFORMATION WITH RELATION TO THE NATURE OF THE SURGERY NEEDS TO BE COLLECTED FROM PHYSICIAN. NO FIXATION NOTED. SURGICAL INCISIONS NOTED AT LEVEL OF C3-C5. CURRENTLY DOES NOT USE ORTHOSIS.

• MOST RECENTLY HAS HAD INCIDENCE OF DIARRHOEA

• STATES THAT HE WANTS TO GET BACK TO WORK AS A FACTORY WORKER, AND THAT HE WANTS TO BE STRONG AGAIN AS A FORMER WEIGHTLIFTER

PAIN

• CURRENTLY EXPERIENCES PAIN IN THE RIGHT INGUINAL REGION, ASSOCIATED WITH SWELLING, LOCATED PROXIMALLY ON THE ANTERIOR RIGHT THIGH. (5/10)

• PATIENT ALSO COMPLAINS OF RIGHT SHOULDER PAIN (6/10)

• SHOULDER PAIN INCREASES BILATERALLY WITH IR/ER MOVEMENTS

CURRENT MEDICATION:

• VITAMIN A

• VITAMIN B

• VITAMIN B6

• VITAMIN B12

• USED ONCE DAILY, VIA TABLET FORM

SYSTEM REVIEW: CARDIOVASCULAR/PULMONARY

• B.P: 127/82 MM/HG

• H.R: 62 BPM

• 02 SATURATION: 97%

• RESPIRATORY RATE: 22 BREATHS PER MINUTE

• EDEMA: PROXIMAL RIGHT KNEE, NEARER TO INGUINAL REGION

• AUSCULTATION: NORMAL BREATHING SOUNDS

• ANTERIOR CHEST SHAPE NORMAL

SYSTEM REVIEW: MUSCULOSKELETAL

• GROSS SYMMETRY: UNABLE TO OBSERVE DUE TO LACK OF ADVANTAGEOUS VANTAGE POINT. NO VISIBLE SPINAL ASSYMETRY, CLEAR ATROPHY IN BOTH UPPER AND LOWER EXTREMITY

• PALPATION: BILATERAL MUSCLE WASTING, FLACCID MUSCLE TONE IN TRICEPS, BICEPS, QUADRICEPS, HAMSTRINGS AND CALVE MUSCLE GROUPS

RANGE OF MOVEMENT (ALL FIGURES IN DEGREES)

UPPER EXTREMITY LEFT

SHOULDER-

• FLEXION: 120, EXT: 10

• ABD: 90, ADD:90

• ELBOW:FLEX/EXT: 0-80

• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION

• WRIST:FLEX/EXT: 90

• PIPS/DIPS: WFL

UPPER EXTREMITY RIGHT

SHOULDER-

• FLEXION: 120, EXT: 10

• ABD: 90, ADD:90

• ELBOW: FLEX/EXT:0-80

• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION

• WRIST: FLEX/EXT: 90

• PIPS/DIPS: WFL

RANGE OF MOVEMENT (ALL FIGURES IN DEGREES)

LOWER EXTREMITY LEFT

• HIP:

• FLEX: 90

• EXT: 5

• ABD/ADD: 45

• KNEE: FLEX/EXT:0-130

• DF: 5

• PF: 5

LOWER EXTREMITY RIGHT

• HIP:

• FLEX: 90

• EXT: 5

• ABD/ADD: 45

• KNEE: FLEX/EXT:0-130

• DF: 5

• PF: 5

MUSCLE STRNGTH (USING 5 POINT SCALE)

UPPER EXTREMITY LEFT

SHOULDER-

• FLEXION(C5): 3, EXT: 3

• ABD(C6): 3, ADD:3

• ELBOW: FLEX(C5-C6)3, EXT(C6-C8):3

• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION

• WRIST:FLEX/EXT(C6-T1):3

• PIPS/DIPS/GRIP(C8-T1): 3

UPPER EXTREMITY RIGHT

SHOULDER-

• FLEXION(C5): 3, EXT: 3

• ABD(C6): 3, ADD:3

• ELBOW: FLEX(C5-C6)3, EXT(C6-C8):3

• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION

• WRIST:FLEX/EXT(C6-T1):3

• PIPS/DIPS/GRIP(C8-T1): 1

MUSCLE STRNGTH (USING 5 POINT SCALE)

LOWER EXTREMITY LEFT• HIP:

• FLEX(L2-L3): 3

• EXT(GLUTEAL NERVE): 3

• ABD/ADD(L2/L4):3

• KNEE: FLEX/EXT(L3-L4):3

• ANKLE

• DF(L5): 3

• PF(L5-S2): 3

LOWER EXTREMITY RIGHT• HIP:

• FLEX(L2-L3): 3

• EXT(GLUTEAL NERVE): 3

• ABD/ADD(L2/L4):3

• KNEE: FLEX/EXT(L3-L4):3

• ANKLE

• DF(L5): 3

• PF(L5-S2): 0

MUSCLE STRENGTH/RANGE OF MOTION

TRUNK ANTERIOR

• FLEXION: 0-40

• SIDE FLEXION : 2/5

• ROTATION: 2/5

• CERVICAL: FLEX/EXT, ROTATION R,L, SIDE FLEXION

• ROM: WFL

• STRENGTH: 4/5

TRUNK POSTERIOR

• 0-10

NOTE: JOINTS GENERALLY EDXHIBITED SOFT END FEELS , WITH THE EXCEPTION OF RT. HAND AND ANKLE, WHICH EXHIBITIED HARD END FEELS

SYSTEM REVIEW: NEUROMUSCULAR

• COORDINATED MOVEMENTS: HEEL/SHIN/KNEE- SLOW

• GAIT: UNABLE TO WALK

• LOCOMOTION:LIMITED, PATIENT SEDENTARY

• BALANCE: PT LACKS SITTING BALANCE FOR EXTENDED PERIOD UNSUPPORTED

• MOTOR FUNCTION

• PLIABILITY OF SKIN: EXTREMITIES EXHIBIT DECREASED PLIABILITY

• SKIN INTEGRITY: NO EVIDENCE OF PRESSURE ULCERS

• CONTINUITY/TEMPERATURE: 97.5 F

• PRESENCE OF SCAR/FOOT CONDITION: POST SURGICAL SCARS POSTERIOR TO C3/C5. XEROSIS (DRY SKIN) NOTED AT THE FEET

• PIGMENTATION: NO NOTABLE ABNORMALITIES

ACTIVITIES OF DAILY LIVING

• ROLLING: WITH ASSISTANCE

• LYING TO SITTING: WITH ASSISTANCE

• SITTING TO LYING: WITH ASSISTANCE

• SITTING BALANCE: IMPAIRED

• SITTING TO STANDING: UNABLE

• STANDING BALANCE: UNABLE TO STAND

• REQUIRES ASSISTANCE IN TRANSFER FROM WHEELCHAIR TO BED

SENSORIMOTOR AWARENESS

• TRACKING LOCALIZATION: INTACT

• TACTILE: IMPAIRED

• PIN PRICK: IMPAIRED

• LIGHT MOVING: IMPAIRED

• LIGHT TOUCH: IMPAIRED

• AUDITORY AWARENESS TRACKING LOCALIZATION: INTACT

PERCEPTUAL PROCESSING

• DEEP PRESSURE: INTACT

• TEMPERATURE: INTACT

• 2 PT DISCRIMINATION: INTACT

• STEREOGNOSIS: INTACT

• KINESTHESIA: INTACT

• PAIN RESPONSE: IMPAIRED

SYSTEM REVIEW: COMMUNICATION

• ORIENTATION: WELL ORIENTED, AWARE OF DATE/TIME/SELF ETC

• COGNITION: IS ABLE TO MEMORIZE AND SPEAK WELL

• EMOTIONAL/BEHAVIORAL RESPONSE: SHOWS OPTIMISM TOWARDS RECOVERY AND EXHIBITS POSITIVE BEHAVIOR

• LEARNING: IS ABLE TO LEARN HOME CARE PROGRAM , SHOWING NO EVIDENCE OF LEARNING DISABILITY

ASIA CLASSIFICATIONSENSORY MAX:112, MOTOR SYSTEM MAX: 50

SENSORY

• PIN PRICK LEFT: 76

• PIN PRICK RIGHT: 76

• LIGHT TOUCH LEFT: 76

• LIGHT TOUCH RIGHT: 76

• S4/S5 NOT TESTED

MOTOR

• RIGHT UPPER EXTREMITY: 11

• LEFT UPPER EXTREMITY: 15

• UPPER LIMB TOTAL: 26

• RIGHT LOWER EXTREMITY: 6

• LEFT LOWER EXTREMITY: 15

• LOWER EXTREMITY TOTAL: 21

BARTHEL INDEX

• BOWELS: 1

• BLADDER: 0

• GROOMING:0

• TIOLET USE: 0

• FEEDING: 2

• TRANSFER: 1

• MOBILITY: 0

• DRESSING: 0

• STAIRS: 0

• BATHING : 0

• PATIENT’S SCORE: 4/20

PROBLEM LIST. PROGNOSIS: GUIDED

• EDEMA: PROXIMAL RIGHT KNEE, NEARER TO INGUINAL REGION

• BILATERAL MUSCLE WASTING, FLACCID MUSCLE TONE IN TRICEPS, BICEPS, QUADRICEPS, HAMSTRINGS AND CALVE MUSCLE GROUPS

• PAINFUL IR/ER

• PAIN RESPONSE: IMPAIRED

• BARTHEL IDEX SCORE LOW (4/20)

• PT IMPRESSION: CERVICAL TRAUMA WITH PARTIAL COMPRESSION INJURIES TO C3-C5, L5/S1

• DF/PF ROM: 5

• PIPS/DIPS/GRIP(C8-T1): 1

• RIGHT PF(L5-S2): 0

• SITTING BALANCE: IMPAIRED

• SITTING TO STANDING: UNABLE

• STANDING BALANCE: UNABLE TO STAND

• TACTILE: IMPAIRED

• PIN PRICK: IMPAIRED

• LIGHT MOVING: IMPAIRED

• LIGHT TOUCH: IMPAIRED

ASIA IMPAIRMENT CLASSIFICATION:D- INCOMPLETE INJURY, MOTOR FUNCTION IS PRESERVED BELOW THE NEUROLOGICAL LEVEL, AND AT LEAST HALF OF KEY MUSCLES BELOW THE NEUROLOGICAL LEVEL HAVE A MUSCLE GRADE OF 3 OR MORE

PLAN OF CARE

SHORT TERM GOALS

• PAIN MANAGEMENT

• DEEP BREATHIG EXERCISES TO MAINTAIN LUNG FUNCTION

• TRANSFER TRAINING

• DECREASE EDEMA AT RIGHT LEG

LONG TERM GOALS

• INCREASE MUSCLE STRENGTH TO 4/5 AT U.E AND L.E.

• INCREASE SITTING BALANCE TO INDEPENDENT LEVELS

INTERVENTION

CLINICAL • HOT PACK 20’’ FOR PAIN

MANAGEMENT (SHOULDER)

• INCLINE TABLE (80 DEGREES)

• OCCUPATIONAL THERAPY

• ICE, COMPRESSION, ELEVATION OF RIGHT LEG

• ACTIVE ASSISTED U.E AND L.E. EXERCISES

• PROPRIOCEPTIVE STIMULATION

HOME CARE

• ASSISTIVE DEVICES SUCH AS POWER WHEELCHAIRS, REACHERS, SHOWER CHAIRS ETC WOULD BENEFIT THIS PATIENT

• BALANCED FOREARM ORTHOSIS(BF0) TO ASSIST WITH GROOMING ETC

• POSTURAL AND POSITIONAL EDUCATION

SPINAL CORD INJURY

POINTS TO NOTE• NEUROLOGICAL LEVEL: THE MOST DISTAL

LEVEL AT WHICH BOTH MOTOR AND SENSORY MODALITIES ARE INTACT

• SKELETAL LEVE: THE LEVEL AT WHICH, BY RADIOLOGICAL EXAM, THE GREATEST VERTEBRAL DAMAGE IS FOUND

• MOTOR LEVEL: THE MOST DISTAL KEY MUSCLE GROUP THAT IS GRADED 3/5 OR GREATER WITH THE SEGMENTS PROXIMAL GRADED NORMAL 5/5 STRENGTH

• THE MOST DISTAL DERMATOME TO HAVE NORMAL SENSATION FOR BOTH P AND LT ON BOTH SIDES

LIMITATIONS

• PATIENT WAS ONLY ASSESSED ONCE

• UNABLE TO OBSERVE IN PRONE

• UNABLE TO CARRY OUT O.T. EXAMINATION

• UNABLE TO SECURE DETAILS OF SURGICAL INTERVENTION

• DID NOT SECURE ENOUGH ADL AND HOME ENVIRONMENT INFORMATION

REFERENCES

• DELISA, J. (2010). PHYSICAL MEDICINE AND REHABILITATION. BALTIMORE: LIPPINCOTT WILLIAMS AND WILKINS.

• AMERICAN SPINAL INJURY ASSOCIATION. INTERNATIOAL STADARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY. CHIGACO,IL:ASIA;1992.