Spinal Cord Injury Discussion Questions

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SCI Case Study: Physical Therapy Evaluation HISTORY Chart Review: Pt is Jose Martinez, a 22-year-old male from Miami, FL who works as a HVAC technician & sustained an incomplete SCI stemming from a physical altercation that included a gunshot wound (GSW) into his back 4 weeks ago. The pt also sustained a mild concussion and and significant bruising to the face and thorax. Pt underwent emergency surgery to remove bullet from left side with good recovery and was then transferred to an inpatient rehabilitation hospital for 3 weeks with good progress. PMH includes exercise-induced asthma, and current medications include acetaminophen for pain & Paxil for anxiety, both used PRN. Pt uses abdominal binder with out-of-bed activities to improve acclimation to upright posture. Pt has been recently referred to outpatient physical therapy to continue addressing functional limitations. Diagnosis: incomplete SCI Brown-Sequard’s Syndrome, T12 Level, Asia C SUBJECTIVE Pt reports not feeling pain since he recently took his pain medication. He reports living with his parents in a 2-story home and adds that there is a railing present to one side. He has been relying on his mother to assist him with some ADLs and admits feeling depressed, sometimes anxious, and concerned that he will not regain his independence. OBJECTIVE Appearance/Rest Posture/Equipment: Pt found supine on the mat, standard wheelchair nearby with abdominal binder, set of axillary crutches, and AFO (recently issued) on the seat. Pt provides consent for physical therapy treatment. Systems Review Cognition/Communication: Pt is alert & oriented x 3, and able to follow commands well. Although demonstrates cooperation, pt appears with low affect and unmotivated to participate. Cardiovascular/Pulmonary: BP = 125/76 mm Hg; HR = 60 bpm; RR = 10 Integumentary: Spinal surgical incisions fully-healed and no signs of irritation. Musculoskeletal: (B) UEs Gross ROM & MMT are WFLs; (B) LEs with PROM WFLs, but with impaired MMT to some key muscle groups. Trunk musculature also demonstrates mild deficits due to prolonged rest in bed and sitting (self-reported by pt). Neuromuscular: Active movement impaired to (B) LEs Psychiatric: Pt with recent psychiatric evaluation on record, and diagnosed with PTSD. Pt has experienced episodes of panic attacks and bouts of depression since the trauma. Tests and Measures Anthropometrics: Height 5'10", Weight 178 lbs, BMI 25.5 (20-25 is normal). Range of Motion: PROM to proximal (B) UEs. Trunk motion limited ~50% in all directions 20 to prolonged dependent rest. (B)LEs: limitations due to mild tightness to hip flexors, knee flexors, and ankle plantar flexors. SCI Case Study: Physical Therapy Evaluation Reflex Integrity: Bilateral DTRs to biceps (C5,C6) & triceps (C7)= 2 (normal); Right Patellar (L4) & Achilles (S1)= 1 (hyporeflexive) Motor Function, Control: (B) LEs demonstrate low-tone and weakness to bilateral LEs to key muscle groups (see Table) Muscle Performance: Manual muscle test grades- C3 through T1 myotomal testing was Normal. Impaired muscle strength reported below: Trunk Motion Flexion Extension (Thoracic & Lumbar) Rotation Lateral flexion Key Muscle(s) Hip flexors (L2) Knee extensors (L3) Ankle dorsiflexors (L4) Long toe extensors (L5) Ankle plantarflexors (S1) (R) Strength (L) Strength 3+/5 3/5 3+/5 NT 3/5 NT (R) Strength 3/5 3/5 2/5 1/5 1/5 (L) Strength 4/5 4/5 3/5 2/5 2/5 Posture: In unsupported sitting, pt demonstrates tendency to adapt exaggerated lumbar lordosis with ant pelvic tilt 20 to trunk weakness. In standing, pt adopts fwd lean on crutches to stabilize. Gait, Locomotion, Balance: Bed mobility- Mod (I) to roll to both sides, pt favors logroll technique though can perform segmental roll with minimal verbal cueing. Supine → sit with Min (A) due pt request for LEs. Transfers- Mat → W/C transfer Mod (I) with sliding board; Sit→ stand with Min (A) of 1 with max verbal cues for erect posture; Stand → sit with Mod(A) of 1 with standard height chair & due to poor eccentric control. Balance- Sitting: Static Good, and Dynamic Fair+; Standing (w/ binder & AFO donned): Static & Dynamic Fair. Pt appeared apprehensive of perturbations and challenges presented. Gait- Mod (A) with axillary crutches & AFOs donned x 25 ft over even surface due to impaired standing balance, inexperience with AFOs, and reported shoulder pain with crutches. Wheelchair mobility: Pt Mod (I) with self-propulsion 100 ft with standard W/C over even surface; reports feeling fatigue after activity. Sensory Integrity: Above level of lesion, all sensation is normal. Sacral sparring present; Light touch & proprioception diminished from (L) L1- S2 dermatomes; Pin-prick or sharp pain and temperature sensation diminished from (R) L1-S2 dermatomes. Self-Care: The patient is able to self-groom, self-feed, and self-dress with Mod (I), admits to increased time with some ADLs and at times allowing mother to help complete quicker. SCI Case Study: Physical Therapy Evaluation ASSESSMENT/EVALUATION: Pt is a 22-year-old man who sustained an incomplete SCI, Brown-Sequards Syndrome, at T12 level (ASIA C) as a result of physical altercation involving a gunshot wound. Pt demonstrates motor and sensory deficits affecting primarily trunk and (B) LEs which are limiting functions such as transfers, standing, and ambulation. Pt demonstrates some apathy, related to psychosocial factors, but was cooperative with activities. FIM: bed mobility 6 (Mod Ind), transfers 4 (Min A), locomotion 4 (Mod A) Problem List 1. Decreased purposeful movement of (B) LEs 2. Dependent in functional mobility (transfers and gait) 3. Lacks postural control in sitting and more significantly in standing 4. Decreased muscle strength & endurance of trunk & (B) LEs musculature 5. Decreased ability to perform self-care activities in standing posture Diagnosis: Patient demonstrates impaired motor function due to incomplete neurologic injury (SCI) ASIA C. Prognosis: Over the next month the patient will demonstrate improved motor function & control for improved functional independence. The potential to reach rehab goals is good secondary to type and level of injury and patient’s premorbid medical status. Plan of Care (POC): Short-Term Goals (actions to be achieved by 2 weeks) 1. Patient will perform supine → sit & sit → supine w/ Mod (I). 2. Patient will demonstrate trunk control & proper posture in sitting for >5 minutes while performing self-care activities with (I)’ly. 3. Patient will demonstrate transfer sit → stand with SB(A) from standard height level. 4. Patient will demonstrate trunk control in static standing with a Good balance grade for at least 3 minutes in preparation for standing & ambulation activities. 5. Patient will ambulate w/ AD & AFOs properly donned at least 75 ft with Min(A) on level surfaces, including turns. 6. Patient will perform HEP w/ minimal verbal cues or demonstrations. Long-Term Goals (actions to be achieved by 4 weeks) 1. Patient will be independent in dynamic sitting activities for self-dressing & grooming. 2. Patient will demonstrate dynamic sitting balance grade of Good for (I) with sitting ADLs. 3. Patient will demonstrate transfer of sit → stand with Mod (I) from reduced height surfaces. 4. Patient will stand for unsupported for at least 10 minutes with balance grade of Good to perform self-care activities (i.e., brushing teeth) with Mod (I). 5. Patient will amb w/ AD & AFOs properly donned >200 ft with SB(A) on level surfaces with obstacles. 6. Patient will negotiate 10 steps with one-rail & AFOs donned with Min(A) to be able to use upstairs bedroom at parent’s home. 7. Patient will perform HEP independently. Interventions: Modalities (PRN), Therapeutic exercises & activities, Neuromuscular Reeducation, Manual therapy techniques, AD fitting & training, Gait training, Pt/family education SCI Case Study: Physical Therapy Evaluation 1 point 1 point 1 point 1 point 1 point EXTRA CREDIT (for Final Exam) Treatment Planning Questions 1. Based on the patient’s diagnosis, what would you anticipate is the patient’s functional potential and overall prognosis over the next few months? Explain your rationale. 2. Since Jose was a victim of a physical altercation it is logical to assume that his PTSD and bouts of anxiety and depression are related to his trauma. How do you think this will affect his recovery? And, what can the PTA do to overcome this possible challenge? 3. Based on the physical therapy evaluation it seems that Jose has some muscle tightness due to him spending prolonged periods in sitting or in bed. What are at least TWO stretches that you would include in his home exercise program? Describe how each stretch should be performed, including dosage. 4. Assume Jose has improved their standing endurance & tolerance to >10 minutes with handhold support, allowing him to perform some standing exercises for strengthening. Describe at least TWO appropriate therapeutic exercises and provide a functional rationale for each. You must include a description of each exercise that includes positioning, equipment, and dosage for full credit. 5. Due to Jose’s sensation deficits he is clearly at risk for issues of skin integrity, especially as he begins to use his ankle-foot orthoses (AFOs) more often. What are at least TWO strategies that you would teach Jose to use so that he can best avoid any issues of skin breakdown with daily use of his AFOs?
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Case Study

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Case Study
Question 1
The patient has a high chance of regaining their functional ability in the next few months.
Research shows that more than three-quarters of patients with incomplete SCI Brown-Sequard
syndrome (BSS) recover most of their functional abilities, including their motor, cognition, and
communication potential, by the time they are discharged from the rehabilitation. More
specifically, it is expected that the patient will regain more than half of his functional abilities
within the first two months. After that, the recovery will slow down up to six months and then
improve fast up to two years. The rationale behind the fast recovery of functional abilities within
a short time in patients diagnosed with BSS is neuroplasticity utilization. The spinal cord makes
adaptive adjustments through neuroplasticity and modifies its neural circuitry (Moskowitz &
Schroeppel, 2018). This allows the functions altered by the spinal injury to be reorganized and
regained through continuous therapy and practice. Besides, the neural pathways in the unaffected
areas are able to use neuroplasticity to handle the affected functions and improve them since BSS
only damages one part of the spinal cord. In other words. Neuroplasticity stimulates the spinal
cord, reinforcing weakened functions. As such, it is anticipated that Jose Martinez will regain
trunk control and proper posture while engaging in self-care activities for at least five minutes
within tw...

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