The Role of Occupational Therapy in Acute Spinal Cord Injury

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Introduction

Rehabilitation process in the spinal cord injury (SCI) is usually divided into acute, subacute and chronic phase. The definition of each of the phases varies, however it is commony accepted that the natural neurorecovery process sets the timing for each phase. The acute and subacute periods lasts around 18 months post-injury, and is followed by the chronic stage when the neurorecovery has plateaued. During the acute spinal cord injury phase the focus is on:

• preventing secondary complications
• promoting and enhancing neurorecovery
• maximizing function
• initiating activities leading to long-term maintenance of health and function.

The Occupational Therapists (OT) belong to the multidisciplinary team in spinal cord injury. Their role in the rehabilitation of the spinal cord injury patients include enhancing patients' daily life activity execution and fine movement, teaching how to use compensatory strategies, finding solutions for the patients' environment adaption to fulfil the common goal of achieving total social inclusion.

The Acute Phase of SCI

The acute phase of spinal cord injury takes place immediately after the injury and is the result of initial trauma . During this traumatic event the spinal cord can become compressed, sheared, lacerated, stretched, distracted. Its vascular supply can also haemorrhage or become constricted. Therefore the first response in SCI includes resuscitation, stabilization, and critical care to determinate and localise specific injuries. Patient is initially immobilised and rehabilitation begins when stabilisation of the spinal cord is obtained, which occurs with patient still on the intensive care unit (ICU). Secondary complications occurring in the acute phase of spinal cord injury include:

• Disruption of the blood spinal cord barrier leading to the infiltration of inflammatory cells
• The release of inflammatory cytokines
• Initiation of proapoptotic signaling cascades
• Release of excitatory neurotransmitters causing excitotoxicity, and ischemia.

Regardless of the patient's receiving initial intervention in a specialised SCI unit or in a non-specific unit, the intervention provided by all members of the team should remain the same.Clinical strategies in the management of the acute spinal cord injury are as follows:

• Surgical decompression to provide relief from mechanical pressure
• Inhibition of the inflammatory response contributing to secondary damage in SCI
• Blood pressure management to decrease the affect of hypotension leading to spinal cord ischemia and secondary damage
• Variety of pharmacological management (most of them in clinical trials) to reduce neuronal loss, minimise lesion size, promotes tissue sparing, reduction of inflammation and excitotoxicity, stimulation of axonal regeneration, facilitation of survival of injured neurons, and promoting neural regeneration and axonal growth.
• Cell-Based therapies to modulate the inflammatory response, providing trophic support, axon remyelination, and neuronal regeneration.
• The use of biomaterials to guide axonal regrowth (clinical trial)
• Physiological approaches including:
  • Therapeutic hypotermia to inhibit the systemic inflammatory response
  • Cerebrospinal fluid (CSF) drainage to improve spinal cord perfusion

Occupational Therapy

It is difficult to find a single definition of occupational therapy (OT) which capture its complexity. There are number of countries in the world that do not yet came up with a definition of the occupational therapy.

The following is the definition provided by the World Federation of Occupational Therapists:

"Occupational therapy is a client-centred health profession concerned with promoting health and wellbeing through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement".

The occupational therapists are part of the multidisciplinary spinal cord injury team. During the acute phase this team can consist of:

1. Surgeon – spine  / neurology / orthopaedics
2. Physician – rehabilitation, other specialists (intensivist and neurologist)
3. Nurse
4. Patient Care Technician/Patient Care Assistant
5. Physiotherapist/Physical Therapist
6. Occupational Therapist
7. Speech Therapist/ Speech Language Pathologist
8. Social worker/Case Manager
9. Clinical psychologist

The Role of the OT in SCI

The role of the occupational therapists in the rehabilitation of individuals with a spinal cord injury is information-given, as oppose to decision-making role.This approach allows for development of a non-dependent relationship between the patient and the clinician. It facilitates communication as the patient develops informed decision-making skills. Active participation in their care during the acute phase of spinal cord injury will help the patients to develop future skills in negotiation environmental barriers, avoiding preventible medical complications and solve problems following discharge from the hospital or rehabilitation centres.

“Regardless of the physical ability of a person with SCI, he or she can still be in control of directing others to assist in this task unless the person with the SCI is cognitively or intellectually impaired”

Therapeutic Management in Acute SCI

General Guidelines

1. Always seek medical clearance before mobilising a spinal cord injured patient
2. Understand and know what medical precautions are advised by the physicians/surgeons
3. Educate, but do not overwhelm with too much information
4. Make teaching skills sessions practical and link to daily routine
5. Involve the patient and the family from the beginning
6. Be flexible with your time. Multiple brief sessions during the day are a good solution: two 15 minutes session per day may be helpful.

Preventing Secondary Complications

Skin Management

Positioning in Bed and In Wheelchair:

Goals for proper positioning in bed:

• Prevent pressure ulcers
• Maintain range of motion
• Prevent pulmonary complications

There is a lack of conclusive guidelines on positioning or repositioning techniques for pressure ulcers prevention in bed. These strategies vary greatly and should be flexible. However, education remains the most powerful strategy for best outcome.

General guidelines:

• Avoid the 90° lateral position because of the risk of pressure ulcers development over the trochanters.
• The lowest degree of head of bed elevation should be maintained consistent with the medical condition.
• Avoid the head of bed 30 degrees or higher as it increases the peak interface pressure between the skin at the sacral area and the support surface. As the a head of a bed is elevated more than 45 degrees the affected area’s skin-bed interface pressure that is greater or equal to 32 mm Hg increases as well.
• Repositioning frequency should be determined by the individual's tissue tolerance, activity level, general medical condition, observed skin condition, and the type of the support surface used.
• During turning in bed a person should always be lifted as opposed to dragged across a surface in order to prevent shear related injuries. Use of sheets is recommended. Avoiding shear is also important in minimising skin breakdown during transfers from one surface to another.

Goals for proper wheelchair positioning:

• Provide postural support
• Maintain tissue integrity
• Prevent tissue trauma

Skin protection is optimised when the patient sits fully upright (not with pelvis in posterior pelvic tilt which places increased pressure over the sacrum) in an appropriate wheelchair with a specialised pressure cushion.

General guidelines:

• Re-evaluate periodically wheelchair/seating support surface and associated equipment for posture and pressure redistribution
• Select a pressure redistribution cushion
• Provide adequate seat tilt to prevent sliding forward in the wheelchair/chair
• Adjust footrests and armrests to maintain proper posture and pressure redistribution
• Avoid the use of elevating leg rests if the individual has inadequate hamstring length
• Tilt the wheelchair before reclining
• Do not use ring or donut cushion

Instruction on pressure relief technique:

• Teach individuals to perform or direct the most appropriate pressure relieving maneuvers
• Establish pressure relief schedules that prescribe the frequency and duration of effective weight shifts

Conduct and instruct how to conduct visual and tactile skin inspection:

• Combine with daily routine: inspect the skin before or after washing
• Provide patient with equipment for skin inspection: long-handle mirror, camera

Practice good hygiene:

• Educate patient and family on good hygiene routine
• Clean the area immediately after the bowel movement
• Keep genital area clean and dry

Prevent oedema:

The limited activities of the muscles as a result of the paralysis are causing reduction in venous and lymphatic return capacity, which leads to oedema. When left unmanaged, oedema can effect hand position including loss of tenodesis grip, wrist positioned in flexion, metacarpalphalangeal joint (MCP) in hyperextension, thumb in adduction, and flexion of proximal and distal interphalangeal (PIP and DIP) joint. Oedema prevention is very important to assure patient's ability to use their hands:

• Assure proper feet and arms positioning in the wheelchair (leg rests, armrests)
• Elevate arms in bed (propping on the pillows)
• Use custom-made hand splint
  • Splinting is considered a standard care for individuals with cervical spinal cord injury
  • Hand splinting should start as soon as possible after injury
  • Resting hand splints are recommended for night use for all levels of cervical SCI
  • Wrist splints are recommended for day use for individuals without active wrist movement
  • Static splinting with firm volar pressure to maintain range of motion and slight shortening of the finger flexors
• Apply compression gloves.

Prevention of Respiratory Complications

Respiratory complications that occur during the acute care phase of hospitalization are a primary determinant of both length of stay and cost of hospitalization among patients with acute tetraplegia. Most common respiratory complications with C1-C4 spinal cord injury include (from the most to the least frequent)

• atelectasis
• pneumonia
• respiratory failure
• pleural effusions.

According to Berlly and Shem 65% of patients with T1-T12 spinal cord injury have severe respiratory complications.

General Guidelines for prevention of respiratory complications:

• Start immediately for all patients with acute spinal cord injury
• Help with secretion mobilisation:
  • Be aware of contradictions for assisted coughing, including unstable spine in traction, internal abdominal complications, fractured ribs, and a recently placed vena cava filter
  • Manual cough assist
  • Postural drainage

• Work with the team on safe swallowing
  • Be aware of signs and symptoms of aspiration
  • Incorporate mealtimes in the patient’s sitting times to ensure good posture whilst eating
  • Ensure patient's access to call button

You can learn more about respiratory complications in SCI from Melanie Harding (Skeen) course Respiratory Management Following a Spinal Cord Injury.

Prevention of Joint Contractures

Upper and lower extremities contractures can develop in acute spinal cord injury due to:

• Static positioning following inability to move joints throughout the full normal range
• Imbalance between the agonistic and antagonistic muscles due to asymmetries in strength in incomplete SCI
• Oedema altering hand and wrist resting position
• Development of spasticity

The presence of joint contractures can be associated with decreased functional ability. It was found, that contractures have a high influence on Quality of Life (QoL).They can lead to pain and deformity and ultimately contribute to decreased levels of independence.

Prevention strategies include:

• Positioning:
  • Position the arm in abduction and external rotation while the patient is in supine
  • Maintain fingers in curled position and wrist in slight extension for patients with C6/7 spinal cord injury to encourage tenodesis grasp
  • Maintain arm in extension for patients with C5/C6 spinal cord injury to avoid positioning the arm in flexion

• Pain management:
  • Proper handling techniques during transfers and positional changes:
    • Do not pull on the arm when positioning or transferring the patient
    • Ensure that the whole arm is supported in all positions to avoid gravity pulling on joints and causing pain.

• Passive range of motion:
  • Ensure the wrist remains mobile
  • Encourage active wrist extension
  • Do not overstretch the finger flexors – do not stretch/straighten the fingers with wrist in extension
  • Always straighten fingers with wrist in flexion and curl fingers in with wrist in extension.
  • Educate the patient and family on proper range of motion technique
  • Maintain web space – splinting might be required

Mobilisation

Goals for early mobilisation:

• To reduce respiratory complications
• To reduce pressure over the sacrum
• To improve psychological well-being
• To assist with bowel management

Guidelines for early mobilisation:

• Understand and adhere to early mobilisation precautions
• Assure that the wheelchair and seating system is the most appropriate for patient's condition, size and patient's ability to direct or perform pressure relief
• Know how to manage postural hypotension:
  • Slow and gradual mobilisation
  • Consider abdominal binder
  • Consider lower limb wrapping or use of compression stocking
  • Know the recovery techniques in case patient has fainted
    • Tilt the chair
    • Lift both legs above the heart
    • Slowly press on patient’s abdomen 

• Develop a sitting schedule, for example out of bed for a meal time.

Retraining for Activities of Daily Living (ADLs)

"The role of the occupational therapist (OT) is to enable the person with SCI to resume participation in their meaningful occupations such as work, activities of daily living and leisure."

Goals for retraining for ADLs:

• To be able to control the hospital environment (call button, telephone, bed controls)
• To be able to direct all aspects of basic ADLs

Guidelines for retraining for ADLs:

• Involve patient in decision-making (patient-centred approach)
• Assure access to adequate resources
• Collaborate with multidisciplinary team to improve outcome
• Know your patient's functional expectations and pre-morbid level of function
• Consider cultural factors, patient's views and expectations

ADL retraining:

• Range of motion and strengthening training as muscle strength is a prerequisite for training any activities of daily living and self-care, including feeding, bathing, dressing and grooming.
• Provide the patient with basic environmental control
• Facilitate communication for ventilated patients: use of communication boards
• Ensure that the patient is oriented daily to time, place, day of the week, etc.

Psychological Support

Goals for psychological support:

• To encourage effective coping strategies
• To encourage health-promotion behaviours
• To encourage participation and “independence”

Guidelines for psychological support for the patient and their families:

• Meet patient and family members information needs
• Discuss patient’s recovery prognosis, the impact of SCI on the patient’s functional independence, how to manage secondary complications, and what to expect in rehabilitation
• Continuously repeat, reinforce and clarify information provided
• Promote realistic hope and focus on what the patient is capable of doing while being honest about their prognosis
• Consider spiritual needs of patients and their family members during acute spinal cord injury

Resources

• Prevention and Treatment of Pressure Ulcers: Quick Reference Guide
• Minkel JL. Seating and Mobility Considerations for People With Spinal Cord Injury. Physical Therapy, 2000; 80 (7): 701–709.
• Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):403-79.